Independent Predictor Of Success Research Articles

Predicting the success of non-invasive ventilation in preventing intubation and re-intubation in the paediatric intensive care unit

To determine whether physiological parameters and underlying condition can be used to predict which patients can be managed successfully on non-invasive ventilation (NIV). Review of case notes and computerised data of every paediatric intensive care unit (PICU) admission over 7years where NIV was commenced. Data immediately prior to commencing NIV and 2h after its establishment was collected. Univariable and multivariable statistical analysis was performed to compare variables. Eighty-three patients commenced NIV attempting to avoid intubation and 64% succeeded. Those who failed required a higher FiO2 (0.56 vs. 0.47, p=0.038), had higher respiratory rates (53.3 vs. 40.3breaths/min, p=0.012) and lower pH (7.26 vs. 7.34, p=0.032) before NIV and higher FiO2 after NIV commenced (0.54 vs. 0.43, p=0.009). Those with a respiratory diagnosis were more likely to be successful. Patients with oncologic disease, particularly if septic, were less likely to avoid intubation using NIV. Multivariable models showed that after adjustment for mode of NIV and underlying diagnosis, respiratory rate before NIV was an independent predictor of success [adjusted odds ratio (OR) 0.95 (0.91, 0.99), p=0.01]. Eighty patients were extubated to NIV but 15 required re-intubation. Those re-intubated had a higher systolic blood pressure (104 vs. 77.9mmHg, p=0.001) and diastolic blood pressure (64.5 vs. 54.1mmHg, p=0.0037) after extubation. Multivariable models showed that systolic blood pressure 2h after extubation was independently associated with outcome [adjusted OR 0.96 (0.93, 0.99), p=0.007]. Parameters relating to respiratory and cardiovascular status can determine which patients will successfully avoid intubation or re-intubation when placed on NIV. Underlying disease and reason for admission should be considered when predicting the outcome of NIV.

Stone measurement by volumetric three‐dimensional computed tomography for predicting the outcome after extracorporeal shock wave lithotripsy

To evaluate the efficacy of stone volume measured using a three-dimensional (3D) reconstruction of preoperative non-contrast computed tomography (NCCT) as an independent predictor of success after extracorporeal shock wave lithotripsy (ESWL) of upper urinary tract calculi. We evaluated preoperative NCCT in 94 patients who had ESWL for solitary upper urinary tract calculi of 4-20 mm in diameter. Axial images were used to measure the skin-to-stone distance (SSD), Hounsfield Unit (HU) density and axial stone diameter. Stone volume was calculated on a volume-rendered 3D image for each stone. Maximum stone length was determined by comparative measurements of each stone in coronal, sagittal and axial planes, and was also measured on a plain abdominal film before ESWL. For ESWL we used the DoliS lithotripter (Dornier Medical Systems, Marrietta, GA, USA). A plain film at 6 weeks was used to categorize patients as stone-free (SF) or with residual stone. In all, 58 (62%) patients were SF and 36 (38%) had RS; the mean stone volume was significantly different between these groups (274 vs 464 microL, P = 0.002). Logistic regression analysis showed that stone volume was the strongest predictor of SF status (P < 0.001), compared to peak HU (P = 0.015), mean HU (P = 0.04) and axial stone diameter (P = 0.006). The body mass index, SSD and maximum stone length on NCCT or a plain film did not predict success. A stone volume of <500 microL best predicted treatment success (P < 0.001) with 72% of patients with a stone volume of <500 microL having a successful outcome, vs only 27% with a stone volume of >500 microL. Our study suggests that stone volume is an optimal predictor of SF status after ESWL of solitary upper urinary tract calculi.

Decline in Number of Elevated Blood CD3+ CD56+ NKT Cells in Response to Intravenous Immunoglobulin Treatment Correlates with Successful Pregnancy

Patients with elevated blood natural killer (NK) cells may be offered intravenous immunoglobulin (IVIG) treatment, but there is controversy about the utility of blood NK cell testing. Human CD56(+) NK cells include several subpopulations that include the putatively cytotoxic CD56(+) CD16(+) subset. In mouse models of pregnant failure, NKT cells appear to be important. However, a mouse model may only be pertinent to a subset of patients, as recurrent pregnancy failure is a heterogenous group. An ethics-approved observational study was done to observe the effect of treatment on total blood lymphoid cells, and subsets of CD56(+) blood lymphocytes including CD56(+) CD3(+) NKT cells determined by flow cytometry, and to correlate with pregnancy outcome. Fifteen fertile women with a history of successful pregnancy and thirty-one women suffering from repeated implantation failure or recurrent spontaneous abortion provided serial blood samples during one menstrual cycle or prior to and during treatment. IVIG was administered to the latter group with or without heparin/aspirin. Eight of thirty infertile women presented with high numbers of CD56(+) CD3(+) NKT cells, which declined after treatment with IVIG. The elevated NKT cell group with or without concomitant autoimmunity achieved a significantly higher successful pregnancy rate over the course of the study, as compared to women with average numbers of NKT cells and no evidence of autoimmunity (P = 0.018). Elevated NKT levels alone was an independent predictor of success on treatment (P = 0.003). Elevated NKT cells in recurrent pregnancy loss or implantation failure can be ameliorated with IVIG treatment, and result in successful pregnancy. Assay of NKT cell numbers may identify patients who are more likely to benefit from IVIG therapy and merits further examination in randomized phase II studies.

The Effects of Alcohol and Substance Abuse on Sedation during ERCP

Purpose: Unsuccessful conscious sedation is a limiting factor in endoscopic retrograde cholangiopancreatography (ERCP). Some patients become agitated and combative during the procedure. Alcohol and substance abuse may precipitate these reactions. This study was designed to investigate the effects of alcohol and substance abuse on conscious sedation for ERCP. Methods: A retrospective chart review of all patients from the Veterans Administration Hospital in Memphis, Tennessee who underwent ERCP from January 2002 until December 2006 were evaluated. Results: 271 ERCP procedures were done during this timeframe. The indications for the ERCP ranged from diagnostic studies to therapeutic interventions. Benzodiazepines, narcotics, and anti-emetics were used for conscious sedation. This study shows that there is a statistically significant inverse correlation between a history of alcohol and substance abuse and success with conscious sedation during ERCP. Chi-square analysis indicates a statistically significant inverse correlation between a history of alcohol use and success with conscious sedation during ERCP (P= 0.0131). In addition, there is a statistically significant inverse correlation between a history of illicit drug use and success with conscious sedation during ERCP (P= 0.0021). Furthermore, the lack of illicit drug use was also found to be an independent predictor of success (P= 0.0101).Table: The Effects of Alcohol and Substance Abuse on Sedation During ERCPConclusion: This study found that alcohol and substance abuse correlated with unsuccessful sedation during ERCP. In this patient population, general anesthesia may be a safer and more beneficial alternative to conscious sedation.

Clinical characteristics of chronic rhinosinusitis with asthma

Objective This study was directed at identifying clinical features of chronic rhinosinusitis with asthma, and examining the differences of the postoperative outcomes in asthmatics and nonasthmatics. Study design and setting Twenty-one asthmatic and 77 nonasthmatic patients who underwent functional endoscopic sinus surgery (FESS) were entered into the study. The following six parameters were determined in asthmatic and nonasthmatic groups; the presence of allergy, previous sinus surgery, severity of preoperative rhinosinusitis symptoms, improvements in postoperative rhinosinusitis symptoms, preoperative disease extent, and postoperative endoscopic outcomes. Results Symptom scores improved significantly in both asthmatics and nonasthmatics postoperatively, and asthmatics exhibited significantly worse postoperative endoscopic outcomes compared with nonasthmatics. No difference was found in other parameters between two groups. Multivariate analysis revealed asthma continues to be an independent predictor of success. Conclusions The present study found that chronic rhinosinusitis in asthmatics showed worse postoperative outcomes than in nonasthmatics, and every attempt should be made for the improvement of surgical results in these patients.

Role of volume and attenuation value histogram of urinary stone on noncontrast helical computed tomography as predictor of fragility by extracorporeal shock wave lithotripsy

Objectives To test, for the first time, the predictive capability of the total stone volume (TSV) and the attenuation value histogram. Recently, the mean attenuation value (MAV) of urinary stones has been recognized as a predictor of fragility by extracorporeal shock wave lithotripsy. However, properties other than MAV, including the TSV and the heterogeneity of attenuation value histogram, may also be related to fragility. Methods A total of 62 renal and proximal ureteral radiopaque stones treated with extracorporeal shock wave lithotripsy were included in this prospective study. Stones less than 5 mm or greater than 20 mm were excluded. Attenuation value histograms were graphed from the data from noncontrast helical computed tomography scans. The TSV, MAV, and hump existence (HE) on the histogram were also calculated. These parameters were compared between the treatment success and treatment failure groups. Results Of the 62 stones, 6 were excluded, 39 were in the success group, and 17 in the failure group. Of the 56 stones, 16 had a hump and 40 did not on the attenuation value histograms. The TSV, MAV, and HE were significantly different statistically between the two groups ( P <0.001), with an accuracy of 82.1%, 83.9%, and 91.1%, respectively. Also, HE was the only independent predictor of success or failure of extracorporeal shock wave lithotripsy on multivariate analysis ( P = 0.0073). Conclusions Our results have suggested that TSV, MAV, and HE are good predictors of stone fragility. The treatment modality of the stone should be selected according to the HE, which is a practical, simple, and predictive index.

Balanced perspective essential in erosive oesophagitis treatment: Author's reply

Sirs, I thank Dr Gillessen for his interest in our paper detailing the results of the EXPO study. I agree, it is of interest that the previous small study claims non-inferiority for pantoprazole 40 mg relative to esomeprazole 40 mg.1 However, our much larger study has now shown that esomeprazole 40 mg is indeed superior to pantoprazole 40 mg for healing oesophagitis.2 I note that the study by Dr Gillessen was limited to patients with Los Angeles (LA) grade B and C oesophagitis and with treatment groups split into three strata, resulting in fewer than 40 patients per stratum. In addition, Dr Gillessen's claim of non-inferiority appears to ignore the guidelines of the European Medicines Evaluation Agency by using a shifting non-inferiority margin and not a prespecified margin as recommended. Dr Gillessen claims that the significant difference in healing rates for esomeprazole over pantoprazole is not clinically relevant because the difference was <5%. However, in the EXPO study, the assumption of a 5% difference in healing rates was only used to calculate the sample size for a study establishing superiority and was based on previously published healing rates from comparative trials with proton-pump inhibitors (PPIs). It was not a cut-off for the level of clinical relevance. Given the number of patients who are treated with PPIs for erosive oesophagitis, we believe the statistically significant 3.5% improvement in healing rates with esomeprazole relative to pantoprazole is clinically important and represents a clear improvement over pantoprazole for patients with erosive oesophagitis. Moreover, the difference between both PPIs was substantially greater after 4 weeks of treatment and with increasing severity of oesophagitis respectively. I am very sceptical of Dr Gillessen's conclusions based on his selective post hoc analysis of the EXPO study data; most notably, his assertion that the greater proportion of patients with LA grade A oesophagitis in the esomeprazole treatment group could have led to the difference in healing rate between esomeprazole and pantoprazole. In the EXPO study, we performed analyses ‘stratified by baseline oesophagitis severity’ (the standard statistical method to adjust for imbalances in baseline factors that may influence a comparison) and found significant differences in healing rates. Therefore, any imbalance in the distribution of severity in the study groups ‘cannot’ be an explanation for the treatment differences observed in the study. In addition, we have performed logistic regression analyses, which clearly identified choice of PPI as an independent predictor of success.3 I agree with Dr Gillessen that an integrated therapeutic perspective is required in the treatment of oesophagitis, but it is also important that clearly defined symptoms are assessed at baseline and following treatment. The assessment scale favoured in many Atlanta-funded pantoprazole studies (including the study in question by Dr Gillessen) takes no account of the severity of individual symptoms. Indeed an improvement in a patient's overall symptom score (driven by improvements in symptoms such as flatulence) could mask deterioration in a more troublesome symptom such as heartburn. Furthermore, I believe, the EXPO study also provides greater therapeutic relevance because it assessed not only the acute treatment of oesophagitis, but also, in the same patient population, the maintenance therapy with esomeprazole 20 mg or pantoprazole 20 mg. These results are detailed in a manuscript published in Alimentary Pharmacology and Therapeutics and further differentiate esomeprazole from pantoprazole for patients with erosive oesophagitis.4 Finally, there is a wealth of published data on the antisecretory potency of these two drugs derived from cross-over studies showing the superiority of esomeprazole over pantoprazole. Therefore, the EXPO study results showing esomeprazole is more effective than pantoprazole for healing erosive oesophagitis would have been expected.

919-15 Rotational Atherectomy in Chronic Total Occlusions

The purpose of this study was to evaluate the success rate, complication profile and predictors of outcome of rotational atherectomy (RA) after guidewire crossing of chronic total occlusions (CTO). 145 total occlusions were treated in 139 procedures between 1988 and 1993. Of these, there were 112 single lesion procedures. Compared to pts with non-total occlusions (NTOI, pts with CTO were more likely to be male, younger and have a prior MI, but less likely to present with unstable angina or to have diabetes. Lesions were more likely type C (68.7% vs 15.1%, P &lt; 0.0001) and longer (14.8 ± 7.8 vs 8.0 ± 5.6 mm, p &lt; 0.0001). Mean baseline stenosis was 100.0%. Post-Rotablator stenosis was 45.6 ± 17.5%. Post-adjunctive balloon stenosis was 24.6 ± 15.9% while final residual stenosis was 26.9 ± 16.8%. The maximum mean burr size was 1.8 ± 0.26 mm while average vessel diameter was 2.74 ± 0.65 mm. Success without major complications occurred in 91.0%. Dissection occurred in 18.0%, acute in-lab closure in 3.6%, post-Cath lab reocclusion in 3.6%, emergency bypass surgery on 0%, death in 1.4% and NOMI in 4.3% of pts. Based on 49.2% angiographic follow-up, restenosis occurred in 62.5% of pts. Univariate predictors of RA success were pt age (p = 0.02), lesion eccentricity (p = 0.04) and vessel diameter (p = 0.02). In a multivariable logistic regression model, only larger vessel diameter remained as an independent predictor of success (2.8 ± 0.6 vs 2.0 ± 0.5 mm). Older age (p = 0.04) and diabetes (p = 0.01) were univariate predictors of restenosis. However, in the final multivariable logistic model, only diabetes remained a significant predictor. In conclusion, RA for the treatment of CTO has acceptable success and restenosis. Non-diabetics with relatively larger vessel diameter appear to benefit most.