Independent Predictor Of Worse Outcome Research Articles

Brain Natriuretic Peptide Helps Prognosticate Improvement in Renal Function in Acute Heart Failure

Introduction We aimed to evaluate the prognostic implications of improved renal function (IRF) in acute heart failure (AHF) and the relationship with regards to measures of congestion. Hypothesis: AHF patients with IRF experience worse outcomes than those with no change or worsening in renal function, but this may be from insufficient decongestion. Methods The Acute Kidney Injury NGAL Evaluation of Symptomatic heart faIlure Study (AKINESIS) was a prospective, international, multicenter study of AHF patients. We investigated the relationship between IRF, changes in brain natriuretic peptide (BNP) and one-year mortality. IRF was defined as a decrease in creatinine of > 0.3 mg/dl at any time during hospitalization. BNP decrease was defined as ≥ 30% decrease in the last measured BNP compared to admission. Results Among 760 patients investigated, 95 patients (13%) experienced IRF. Patients with IRF had worse renal function and higher BNP on admission compared to those without IRF (creatinine, 2.04 mg/dl [1.60, 2.52 mg/dl] vs. 1.16 mg/dl [0.90, 1.44 mg/dl], p = 0.004; BNP, 846 ng/l [319, 1465 ng/l] vs. 535 ng/l [232, 1059 ng/l], p = 0.006). Both groups had a significant decrease in BNP ( Figure 1 ), though patients with IRF were less likely to experience a ≥ 30% BNP decrease (37% vs. 55%, p = 0.001). Discharge BNP levels were also higher in those with IRF (664 ng/l [265, 1012 ng/l] vs. 308 ng/l [128, 714 ng/l], p Figure 2 ), though after adjusting for confounders, BNP decrease but not IRF was associated with worse outcomes (IRF, adjusted HR 1.29, 95% CI 0.82-2.02, p = 0.269; BNP decrease, adjusted HR 0.61, 95% CI 0.42-0.89, p = 0.010). Conclusions IRF was associated with severe congestion on admission, insufficient decongestion during hospitalization, and residual congestion at discharge. Decongestion but not IRF was an independent predictor of worse outcomes.

Antibody profile may predict outcome in ocular myasthenia gravis.

An unsolved issue remains whether there are clinical and immunological features to predict in a single patient the risk of conversion from ocular Myasthenia Gravis (OMG) to generalized disease (GMG) as 50-60% of patients may progress within 1-2years since onset. Anti-acetylcholine receptor antibodies (AChR Abs) are found in up to 50% of OMG patients; muscle-specific tyrosine kinase antibodies (MuSK-Abs) are present in about 70% of the whole seronegative (SN), who usually develop a severe disease with bulbar involvement. We surveyed a cohort of 175 OMG patients with purely ocular symptoms and we compare the outcome of patients with antibodies to AChR or to MuSK with those seronegative for both Abs (DSN). All patients had purely ocular signs for at least 24months. Gender, age at onset, time to generalization or to worsening in quantitative ocular QMG scores, electrophysiological results were analyzed. Males were 58.9%, females 41.1%. Patients with late onset of symptoms after 50years (LOMG) were 78.3%. We assayed anti-MuSK-Abs in 4.7%, anti-AChR Abs in 38.5%; 57.3% were defined DSN. Thirty-seven patients (21.1%) progressed to GMG during the observational time: 23 were females, 62% of the whole group of the generalized subjects, 75% of MuSK-positive OMG converted to GMG versus the 26.2% of AChR positive and 13.7% of DSN. Statistical analysis showed that gender and presence of antibodies either to AChR or to MuSK were independent predictors of worse outcome; the DSN subjects had lower risk of conversion to GMG.

Prognostic Value of Serum Lactate Levels in Patients Undergoing Urgent Heart Transplant: A Subanalysis of the ASIS-TC Spanish Multicenter Study

Introduction and objectivesTo study the prognostic value of serum lactate in patients under temporary preoperative mechanical circulatory support who underwent urgent heart transplant. MethodsWe conducted a subanalysis of a Spanish multicenter registry recording data on patients under temporary mechanical circulatory support listed for highly urgent heart transplant from 2010 to 2015. Participants selected for the present study were those who received a transplant and who had known preoperative serum lactate levels. The main study outcome was 1-year survival after transplant. ResultsA total of 177 heart transplant recipients were studied; preoperatively, 90 were supported on venoarterial extracorporeal membrane oxygenation, 51 on temporary left ventricular assist devices, and 36 on temporary biventricular assist devices. Preoperative hyperlactatemia (≥ 2 mmol/L) was present in 44 (25%) patients. On multivariable analysis, pretransplant serum lactate was identified as an independent predictor of 1-year posttransplant survival (adjusted HR per 0.1 mmol/L, 1.02; 95%CI, 1.01-1.03; P = .007). One-year posttransplant survival was 53.1% (95%CI, 45.3-60.9) in patients with preoperative hyperlactatemia and 75.6% (95%CI, 71.8-79.4) in those without preoperative hyperlactatemia (adjusted HR, 1.94; 95%CI, 1.04-3.63; P = .039). Preoperative hyperlactatemia correlated with adverse outcomes in patients supported with extracorporeal membrane oxygenation, but not in patients supported on ventricular assist devices. ConclusionsPreoperative serum lactate is a strong independent predictor of worse outcomes in patients undergoing urgent heart transplant on short-term mechanical circulatory support.

Clinical impact of optical coherence tomography findings on culprit plaque in acute coronary syndrome: The OCT-FORMIDABLE study registry.

Aim of this study was to evaluate the clinical impact of the culprit plaque features assessed by optical coherence tomography (OCT) in patients with acute coronary syndrome (ACS). The OCT-FORMIDABLE register enrolled retrospectively all consecutive patients who perform OCT on culprit plaque in patients with ACS in nine European centres. The primary endpoint was the prevalence of culprit plaque rupture (CPR) in patients experiencing major adverse cardiovascular events (MACEs). Secondary endpoint was the prevalence necrotic core with macrophage infiltrations (NCMI) in the patients experiencing MACEs. Two-hundred and nine patients were included in the study. Mean age was 60.1 ± 12.9 years old, 19.1% were females. Main clinical presentation was ST-elevation myocardial infarction (55%). At OCT analysis, CPR was observed in 71.8% patients, while 31.6% presented NCMI. During follow-up (12.6 ± 14.5 months), 11% of the patients experienced MACEs. The presence of CPR (HR 3.7,1.4-9.8, P < .01) and NCMI (HR 3.3,1.6-6.6, P < .01) were independent predictors for MACEs, while dual antiplatelet therapy with prasugrel/ticagrelor at discharge (HR 0.2,0.1-0.6, P < .01) were protective. The protective impact of new antiplatelet drugs was reported only in patients with CPR while in patients without any of the baseline clinical or procedural features impacted on MACEs. CPR and the presence of NCMI are independent predictors of worse outcome. Patients with CPR seem to benefit more of an intensive therapy, both from a pharmacological and interventional point of view. (NCT02486861).

Valor pronóstico de la concentración sérica de lactato de los receptores de trasplante cardiaco urgente: subanálisis del estudio multicéntrico español ASIS-TC

Introduction and objectivesTo study the prognostic value of serum lactate in patients under temporary preoperative mechanical circulatory support who underwent urgent heart transplant. MethodsWe conducted a subanalysis of a Spanish multicenter registry recording data on patients under temporary mechanical circulatory support listed for highly urgent heart transplant from 2010 to 2015. Participants selected for the present study were those who received a transplant and who had known preoperative serum lactate levels. The main study outcome was 1-year survival after transplant. ResultsA total of 177 heart transplant recipients were studied; preoperatively, 90 were supported on venoarterial extracorporeal membrane oxygenation, 51 on temporary left ventricular assist devices, and 36 on temporary biventricular assist devices. Preoperative hyperlactatemia (≥ 2 mmol/L) was present in 44 (25%) patients. On multivariable analysis, pretransplant serum lactate was identified as an independent predictor of 1-year posttransplant survival (adjusted HR per 0.1 mmol/L, 1.02; 95%CI, 1.01-1.03; P = .007). One-year posttransplant survival was 53.1% (95%CI, 45.3-60.9) in patients with preoperative hyperlactatemia and 75.6% (95%CI, 71.8-79.4) in those without preoperative hyperlactatemia (adjusted HR, 1.94; 95%CI, 1.04-3.63; P = .039). Preoperative hyperlactatemia correlated with adverse outcomes in patients supported with extracorporeal membrane oxygenation, but not in patients supported on ventricular assist devices. ConclusionsPreoperative serum lactate is a strong independent predictor of worse outcomes in patients undergoing urgent heart transplant on short-term mechanical circulatory support.Full English text available from: www.revespcardiol.org/en

Association between renal function and outcomes after percutaneous transluminal renal angioplasty in hypertensive patients with renal artery stenosis.

We investigated the impact of renal function on outcomes after percutaneous transluminal angioplasty. A total of 139 hypertensive patients with atherosclerotic renal artery stenosis (mean age, 70 years, 80.6% men) who underwent renal percutaneous transluminal angioplasty were included. Renal function was evaluated on the basis of estimated glomerular filtration rate (eGFR) and albuminuria/proteinuria, and classified into three categories according to eGFR (≥45, 30-44, and <30 ml/min/1.73 m) and albuminuria/proteinuria [normal-to-mild: albumin/creatinine ratio (ACR) less than 3.0, protein/creatinine ratio (PCR) less than 15; moderate: ACR 3.0-30.0, PCR 15-50; severe: ACR > 30.0, PCR > 50 mg/mmol]. During a median follow-up of 5.4 years, 36.0% of patients developed the primary composite end point, including cardiovascular and renal outcomes. In multivariate Cox regression analysis, eGFR less than 30 (hazard ratio 3.47, P < 0.01) as well as severe albuminuria/proteinuria (hazard ratio 2.63, P < 0.05) was an independent predictor of worse outcome. In the subgroup without events within 1 year after angioplasty (n = 117), the outcome differed among the three renal functional categories at 1 year based on eGFR (log-rank χ = 16.28, P < 0.001) as well as on albuminuria/proteinuria (log-rank χ = 8.30, P < 0.05). At 1 year, 24 patients (20.1%) showed at least 20% decrease in eGFR, and their outcome was worse than that in those with at least 20% increase (n = 23) (hazard ratio 3.50, P < 0.05). Multiple logistic regression analysis indicated that pretreatment moderate-to-severe albuminuria/proteinuria was an independent predictor of at least 20% eGFR decrease (odds ratio 2.82, P < 0.05). Impaired renal function, and in particular, a poor response of eGFR to angioplasty, is associated with worse outcome. Therapeutic effectiveness of renal angioplasty seems to be limited in patients with albuminuria/proteinuria.

Predictors of surgical outcomes for severe cubital tunnel syndrome: a review of 146 patients.

Full recovery is unlikely for severe cubital tunnel syndrome, and prognostic factors remain uncertain. We aimed to identify predictors of surgical outcome for these patients. One hundred forty-six patients with McGowan grade III cubital tunnel syndrome were evaluated retrospectively with a minimum follow-up of 2years. All patients underwent either in situ decompression or subcutaneous transposition. The primary outcome measure was postoperative McGowan grade. Predictors included age, sex, dominant hand, disease duration, diabetes mellitus, smoking, alcohol, surgical procedure, follow-up time and preoperative electrophysiological data. Spearman's rank correlation and ordinal logistic regression model were used to assess the effect of independent variables on the postoperative McGowan grade. At the last follow-up, improvement by at least one McGowan grade was reached in 118 cases (80.8%), and complete recovery was achieved in 40 hands (27.4%), while 28 extremities (19.2%) remained at grade III. Older age [per 10-year increase, odds ratio (OR) 2.10; 95% confidence interval (95% CI) 1.55-2.84, p < 0.001], longer disease duration (per 1-year increase, OR 1.31; 95% CI 1.16-1.49, p < 0.001), absent sensory nerve conduction (OR 2.55; 95% CI 1.25-5.21, p = 0.010) and shorter postoperative follow-up (per 1-year increase, OR 0.76; 95% CI 0.65-0.90, p = 0.001) were associated with a higher postoperative McGowan grade. Significant improvement but not complete recovery could be expected following in situ decompression or subcutaneous transposition for severe cubital tunnel syndrome. Older age, longer disease duration, absent sensory nerve conduction and shorter postoperative follow-up are independent predictors of worse outcomes.

Insurance Status Impacts Survival in Burkitt Lymphoma

Introduction:Burkitt lymphoma (BL) is an aggressive non-Hodgkin lymphoma with an estimated 1480 new cases diagnosed in the United States in 2016. BL is simultaneously one of the most aggressive lymphomas, with a tumor volume doubling time of just 24 hours, and one of the most curable, with several clinical trials showing 3-year survival rates over 80%. However, recent studies have identified a significant discrepancy between clinical trial and “real-world” survival, implying access to care may play an important role in BL outcomes. A patient's insurance status represents a major factor in the utilization of cancer therapies and outcomes in the United States. Underinsured patients are more likely to be diagnosed at an advanced stage, receive substandard therapy, and have worse outcomes. We examined the effect of insurance status on survival in adults with BL and compared the impact of insurance status on BL outcomes to that seen in plasmablastic lymphoma (PBL), an aggressive lymphoma that has poor outcomes regardless of treatment.Methods:We used data from the National Cancer Database (NCDB), a nationwide, hospital-based cancer registry jointly sponsored by the American Cancer Society and American College of Surgeons that contains 34 million historical records and captures 75% of newly diagnosed cancer cases in the United States. Commission on Cancer (CoC)-accredited facilities report patients' vital status and date of death to the NCDB annually.We included patients > 18 years old diagnosed 2004-2014 with BL or PBL as the primary tumor who received all or part of initial course of treatment at the reporting facility. Patients missing information on insurance status or survival were excluded, as were those who had non-Medicare/Medicaid government insurance (VA, Indian Health Services). Chi-square tests were used to compare sociodemographic and clinical characteristics by insurance status. All analyses were performed for both BL and PBL and stratified on age 65, due to changes in eligibility for Medicare at that age. Kaplan-Meier survival curves were stratified by insurance status, and log-rank tests were performed. Univariate Cox proportional hazard models were generated to describe the unadjusted associations for the covariables, and multivariable Cox proportional hazard models were generated to estimate the hazard ratio (HR) associated with insurance status when adjusted for prognostic factors.Results:We identified 7,073 BL patients and 475 PBL patients in the NCDB who met inclusion criteria. Of the 5235 BL patients < 65 years, 65.0% had private insurance, 17.2% had Medicaid, 7.6% had Medicare, and 10.2% had no insurance. Of the 1838 BL patients ≥ 65 years, 12.9% had private insurance, 1.5% had Medicaid, 85% had Medicare, and 0.65% had no insurance. Uninsured and Medicaid-insured patients were more likely to be Hispanic or black, have lower socioeconomic status (SES), have B symptoms, be HIV-positive, and have a Charlson-Deyo comorbidity score ≥ 2 when compared with privately insured patients. Medicare patients were more likely to be female, have ≥1 comorbidity, and not receive chemotherapy treatment when compared to privately insured patients. BL patients without private insurance had significantly worse overall survival compared to those with private insurance, regardless of age group (adjusted HR age <65: uninsured 1.41 [95% confidence interval 1.2,1.7], Medicaid 1.17 [1,1.4], Medicare 1.5 [1.2,1.8]; adjusted HR age ≥ 65: uninsured 6 [2.1,17.3], Medicare 1.33 [1,1.8]; see Figure). Conversely, Cox regression models demonstrated that PBL patients without private insurance experienced no significant differences in overall survival in either age group. For BL patients age <65, low SES, presence of B symptoms, advanced stage, HIV-positive status, comorbidity score ≥ 2, and lack of treatment were significant, independent predictors of worse outcomes and contributed to the disparities in survival by insurance status. For BL age > 65, B symptoms, comorbidity score ≥ 2, and lack of treatment were significant, independent predictors of worse outcomes.Conclusion:We identified insurance status as an important predictor of clinical outcomes for BL. Our findings suggest that expanding access to care may improve survival disparities in BL, for which curative therapy exists, but not PBL, where more effective therapies are needed to improve outcomes. [Display omitted] DisclosuresFlowers:Celgene: Consultancy, Research Funding; Bayer: Consultancy; V Foundation: Research Funding; Research to Practice: Research Funding; Infinity: Research Funding; Acerta: Research Funding; National Institutes Of Health: Research Funding; Clinical Care Options: Research Funding; Educational Concepts: Research Funding; Abbvie: Consultancy, Research Funding; Pharmacyclics LLC, an AbbVie Company: Research Funding; OptumRx: Consultancy; Spectrum: Consultancy; Genentech/Roche: Consultancy, Research Funding; National Cancer Institute: Research Funding; Eastern Cooperative Oncology Group: Research Funding; Onyx: Research Funding; Burroughs Welcome Fund: Research Funding; TG Therapeutics: Research Funding; Prime Oncology: Research Funding; Millennium/Takeda: Research Funding; Janssen Pharmaceutical: Research Funding; Seattle Genetics: Consultancy; Gilead: Consultancy.

Sacubitril/valsartan reduces serum uric acid concentration, an independent predictor of adverse outcomes in PARADIGM-HF.

AimsElevated serum uric acid concentration (SUA) has been associated with an increased risk of cardiovascular disease, but this may be due to unmeasured confounders. We examined the association between SUA and outcomes as well as the effect of sacubitril/valsartan on SUA in patients with heart failure with reduced ejection fraction (HFrEF) in PARADIGM‐HF.Methods and resultsThe association between SUA and the primary composite outcome of cardiovascular death or heart failure (HF) hospitalization, its components, and all‐cause mortality was examined using Cox regression analyses among 8213 patients using quintiles (Q1–Q5) of SUA adjusted for baseline prognostic variables including estimated glomerular filtration rate (eGFR), diuretic dose, and log N‐terminal pro‐brain natriuretic peptide. Change in SUA from baseline over 12 months was also evaluated in each treatment group. Patients in Q5 (SUA ≥8.6 mg/dL) compared with Q1 (<5.4 mg/dL) were younger (62.8 vs. 64.2 years), more often male (88.7% vs. 63.1%), had lower systolic blood pressure (119 vs. 123 mmHg), lower eGFR (57.4 vs. 76.6 mL/min/1.73 m2), and greater diuretic use. Higher SUA was associated with a higher risk of the primary outcome (adjusted hazard ratios) Q5 vs. Q1 = 1.28 [95% confidence intervals (1.09–1.50), P = 0.003], cardiovascular death [1.44 (1.11–1.77), P = 0.001], HF hospitalization [1.37 (1.11–1.70), P = 0.004], and all‐cause mortality [1.36 (1.13–1.64), P = 0.001]. Compared with enalapril, sacubitril/valsartan reduced SUA by 0.24 (0.17–0.32) mg/dL over 12 months (P < 0.0001). Sacubitril/valsartan improved outcomes, irrespective of SUA concentration.ConclusionSerum uric acid concentration was an independent predictor of worse outcomes after multivariable adjustment in patients with HFrEF. Compared with enalapril, sacubitril/valsartan reduced SUA and improved outcomes irrespective of SUA.

Abstract P433: Impact of Renal Function on Outcomes After Percutaneous Transluminal Renal Angioplasty in Hypertensive Patients With Renal Artery Stenosis

Objective: Atherosclerotic renal artery stenosis (ARAS) is associated with secondary hypertension. Renal dysfunction is often present in ARAS patients; however, evidence for the impact of pretreatment renal function on outcomes after percutaneous transluminal renal angioplasty (PTA) is limited. Methods: A total of 139 hypertensive patients with ARAS (mean age, 69.5±8.9 years, 112 male) who underwent renal PTA were included. Renal function was evaluated based on estimated glomerular filtration rate (eGFR) and albuminuria/proteinuria, and classified into three categories according to eGFR (≥45, 30-44, &lt;30 ml/min/1.73m 2 ) and albuminuria/proteinuria [normal-to-mild: albumin/creatinine ratio (ACR) &lt;3.0, protein/creatinine ratio (PCR) &lt;15; moderate: ACR 3.0-30.0, PCR 15-50; severe: ACR &gt;30.0, PCR &gt;50 mg/mmol]. The primary end point of this study was first occurrence of the composite of cardiovascular and renal events including all-cause death, myocardial infarction, stroke, adverse aortic events, or end-stage renal failure requiring regular hemodialysis. Results: During a median follow up of 5.4 years, 36.0% (50 of 139) of patients developed the primary composite end point including cardiovascular and renal outcomes. In multivariate Cox regression analysis, eGFR &lt;30 (hazard ratio [HR] 3.47, p &lt;0.01) as well as severe albuminuria/proteinuria (HR 2.63, p &lt;0.05) was an independent predictor of worse outcome. In the subgroup without events within one year after PTA (n=117), the outcome differed among the three renal functional categories at one year based on eGFR (log-rank χ 2 =16.28, p &lt;0.001) as well as on albuminuria/proteinuria (log-rank χ 2 =8.30, p &lt;0.05). At one year, 24 of 117 patients (20.1%) showed a ≥20% decrease in eGFR, and their outcome was worse than that of those with a ≥20% increase (n=23) (HR 3.50, p &lt;0.05). Multiple logistic regression analysis indicated that pretreatment moderate-to-severe albuminuria/proteinuria was an independent predictor of a ≥20% eGFR decrease (odds ratio 2.82, p &lt;0.05). Conclusion: Impaired renal function, and in particular, a poor response of eGFR to PTA, is associated with worse outcome. Therapeutic effectiveness of renal angioplasty seems to be limited in patients with albuminuria/proteinuria.

Predictors and long-term outcome in Greek adults with juvenile idiopathic arthritis: a 17-year continuous follow-up study.

To describe the disease characteristics, continuous course and long-term outcome and to evaluate predictors of outcome in JIA in Greece. We performed a retrospective cohort analysis of 17 years' prospective data on JIA. Outcome assessment included radiographic (modified Sharp-van der Heidje score), articular and extra-articular damage (Juvenile Arthritis Damage Index), functional ability (HAQ Disability Index), and the cumulative percentage time spent in a state of active disease and also in clinical remission off medication (CR) (according to Wallace's criteria). One hundred and two (72 females) patients under regular follow-up were enrolled. The disease age of onset [mean (SD)] was 7.7 (4) years, the interval from onset to last visit was 17.2 (6.7) years and the patients' current age was 25 (5.9) years. At the last follow-up visit, 53 patients (52%) had disease activity, while 23.5% were in CR. The cumulative percentage time spent in a state of active disease and CR over the disease course was 52.6 and 17.8%, respectively. Polyarticular subtype of onset and longer disease activity during the first 5 years were independent predictors of worse outcome. Additional telephone-based interviews of 205 former JIA patients who had been lost to follow-up as adults were performed to extend the interpretation of our findings to a broader JIA population. Almost half (47.6%) of the total cohort of 307 patients were found to be in CR at the final evaluation and 69.7% had no disability. The available data indicate that JIA as a whole is a heterogeneous disease with significant variability in course and long-term outcome.

Racial disparities in outcomes of operatively treated lower extremity fractures.

Whether racial differences are associated with function in the long term following surgical repair of lower extremity fractures has not been investigated. The purpose of this study is to compare how race affects function at 3, 6 and 12months post-surgery following certain lower extremity fractures. Four hundred and eighteen patients treated operatively for a lower extremity fracture (199 tibial plateau, 39 tibial shaft, and 180 rotational ankle fractures) were prospectively followed for 1year. Race was stratified into four groups: Caucasian, African-American, Hispanic origin, and other. Long-term outcomes were evaluated using the short musculoskeletal function assessment (SMFA) and pain scores were assessed at 3, 6months and 1year. There were 223 (53.3%) Caucasians, 72 (17.2%) African-Americans, 53 (12.4%) Hispanics, and 71 (17.0%) patients from other ethnic groups, included in our study population. Minority patients (African-American, Hispanics, etc.) were more likely to be involved in high velocity mechanisms of injury and tended to have a greater percentage of open fractures. Although there were no differences in the rate of wound complications or reoperations, long-term functional outcomes were worse in minority patients as assessed by pain scores at 6months and functional outcome scores at 3, 6 and 12months. Multivariate analysis revealed that only African-American and Hispanic race continued to be independent predictors of worse functional outcomes at 12months. Racial minorities and those on medicaid had poorer long-term function following fractures of the lower extremity. While minority patients were involved in more high velocity accidents, this was not an independent predictor of worse outcomes. These disparities may result from multifactorial socioeconomic factors, including socioeconomic status and education levels that were not controlled in our study. Prognostic Level III.

A snapshot of the oxygenation of mechanically ventilated patients in one Australian intensive care unit.

Hyperoxaemia in patients undergoing mechanical ventilation (MV) has been found to be an independent predictor of worse outcome and in-hospital mortality in some conditions. Data suggests that a fraction of inspired oxygen (FiO2) of 0.4 or lower may produce hyperoxaemia although it is commonly accepted without adjustment in ventilator settings. The primary aim of this study was to observe current practice at one Australian tertiary intensive care unit (ICU) with regard to prescription and titration of oxygen (O2) in patients undergoing MV, in particular whether they received higher FiO2 than required according to arterial blood gas (ABG) results, and whether there was FiO2 titration as a response to initial ABG results during the 12 hours following. A retrospective observational study of 151 ICU patients undergoing MV between November 2013 and February 2014 was conducted, with ABGs as the primary outcome measure. There were 250 ABG measures, with mean FiO2 0.38 (range 0.3-1.0) and mean PaO2 114 mmHg (standard deviation 36). Over all observations, 197 (79%) were of FiO2 ≤0.4, however no patients were ventilated on room air (FiO2 0.21) and 114 (46%) were in the hyperoxaemic range. Oxygen titration (up or down) occurred in 31% of patients. Morning ABGs were taken at a time suggested by ICU guidelines, and on review of these measures, the mean FiO2 was lower than that purported to create toxicity. Subsequently, almost one-third of the cohort had their FiO2 titrated, however there was a floor effect whereby 39%-43% of the cohort received an FiO2 of 0.3.

Reversible Cerebral Vasoconstriction Syndrome: Recognition and Treatment.

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare but increasingly recognized disorder with over 500 cases published in the literature. The condition is characterized by recurrent severe thunderclap headaches with or without other neurological symptoms and diffuse segmental narrowing of the cerebral arteries which is reversible within 3months. RCVS may occur spontaneously but in over 50% of cases, it is associated with various other conditions, including vasoactive medications or illicit drugs and the post-partum state. One third to a half of cases develop hemorrhagic or ischemic brain lesions or a combination of both. Posterior reversible encephalopathy syndrome (PRES) often occurs in association with RCVS and the conditions are likely to share a common pathophysiology. The pathogenesis of RCVS remains uncertain but autonomic dysregulation, oxidative stress, and genetic predisposition are postulated. Significant differential diagnoses include subarachnoid hemorrhage (SAH) due to aneurysmal rupture, cervical artery dissection, and primary angiitis of the central nervous system (PACNS). Although there is no proven treatment, calcium channel antagonists including nimodipine and verapamil have been administered with reported reduction of headache intensity but without effect on the time course of cerebral vasoconstriction. Glucocorticoids have been reported as an independent predictor of worse outcome and should be avoided. The cornerstone of RCVS management remains largely supportive with bed rest and analgesics and removal of precipitating factors. Invasive neurointerventional techniques should be reserved for severe deteriorating cases. The condition is usually benign and self-limited and the majority of patients have a favorable outcome but around 5-10% are left with permanent neurological deficits and rare cases may die. This review details the importance of the early recognition of this increasingly described condition and current treatment recommendations.

RV Contractile Function and its Coupling to Pulmonary Circulation in Heart Failure With Preserved Ejection Fraction: Stratification of Clinical Phenotypes and Outcomes

ObjectivesThis study sought to investigate how right ventricular (RV) contractile function and its coupling with pulmonary circulation (PC) stratify clinical phenotypes and outcome in heart failure preserved ejection fraction (HFpEF) patients. BackgroundPulmonary hypertension and RV dysfunction are key hemodynamic abnormalities in HFpEF. MethodsThree hundred eighty seven HFpEF patients (mean age 64 ± 12 years, 59% females, left ventricular ejection fraction 59 ± 7%) underwent RV and pulmonary hemodynamic evaluation by echocardiography (entire population) and right heart catheterization (219 patients). Patients were investigated by tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) relationship and stratified according to TAPSE/PASP ratio tertiles (1: <0.35; 2: 0.35 to 0.57; 3: >0.57). Specifically, TAPSE/PASP ratio was taken as a noninvasive index of RV to PC coupling based on the correlation with invasively evaluated RV systolic elastance/arterial elastance (r = 0.35; p < 0.0001). ResultsGroups had similar prevalence of comorbidities except for a higher prevalence of atrial fibrillation and kidney dysfunction in tertile 1. Progressively increasing levels of natriuretic peptides, worse systemic and pulmonary hemodynamics, abnormal exercise aerobic capacity and ventilatory inefficiency were observed from the highest to lowest TAPSE/PASP tertile. TASPE/PASP correlated with pulmonary artery compliance (r = 0.69; p < 0.0001). Remarkably, the tertile 1 group distributed along the worse portion of the curve at lower pulmonary artery compliance and higher pulmonary vascular resistances. In addition, the TAPSE/PASP ratio emerged as an independent predictor of worse outcomes. ConclusionsA thorough assessment of RV-PC coupling and RV contractile function stratify HFpEF phenotypes at different level of risk. These observations shift the interest toward therapeutic strategies that may benefit the right heart as primary unmet need in the complex pathophysiology of the HFpEF syndrome.

MP73-04 RACIAL DISPARITIES IN HISPANIC RENAL CELL CARCINOMA PATIENTS

You have accessJournal of UrologyKidney Cancer: Epidemiology & Evaluation/Staging I1 Apr 2016MP73-04 RACIAL DISPARITIES IN HISPANIC RENAL CELL CARCINOMA PATIENTS Alfredo Suarez-Sarmiento, Brian Shuch, and Cayce Nawaf Alfredo Suarez-SarmientoAlfredo Suarez-Sarmiento More articles by this author , Brian ShuchBrian Shuch More articles by this author , and Cayce NawafCayce Nawaf More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1659AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Racial disparities are common in genitourinary cancers, especially renal cell carcinoma (RCC). Limited studies compare whether racial disparities exist among Hispanics with RCC compared to other racial/ethnic groups. In this study, we use data from a single payer healthcare system to investigate if a racial disparity in RCC patients exists between Hispanics and non-Hispanic whites (NHW). METHODS A case-control RCC study was previously conducting on patients receiving care within the Northern California Kaiser Permanente system. We obtained pathologic and epidemiological records from included RCC cases from 1998 to 2008. Patient ethnicity was identified as either Hispanic or non-Hispanic whites. Patient characteristics, comorbidities, tumor characteristics and treatment status were compared. Overall survival (OS) and disease specific survival (DSS) were calculated by the Kaplan-Meier method and a multivariate, Cox proportion hazard model was used to estimate the association of race, comorbidity, and clinico-pathologic variables with survival. RESULTS A total of 2572 patients (2152 NHW, 452 Hispanic) were evaluated. Hispanics were diagnosed with RCC at a younger mean age compared to NHW (59.6 years vs 65.3 years, p <0.0001). Clear cell RCC was more prevalent among Hispanics (88.9% vs 85%, p <0.004). Hispanics were found to have lower AJCC stage at diagnosis (I/II vs III/IV) than NHW (67.4% vs 62.2%, p <0.044). Overall Hispanics were found to have a greater incidence of comorbidities such as chronic kidney disease (2.6% vs 0.7%, p <0.0001), and diabetes (23.8% vs 15.9%, p <0.001), but still were more inclined to receive surgery (84.2% vs 77.9%, p <0.004). On multivariate analysis, the presence of metastases (P <0.001), nodal involvement (P <0.001), increased tumor size (P <0.001), non-surgical management (P <0.001), increasing age (P <0.001), and Hispanic race (P <0.023) were independent predictors of worse outcome. CONCLUSIONS Even within a healthcare system with similar access to care, Hispanics with RCC were younger, had greater comorbidities, and more frequently had clear cell RCC. Despite a lower AJCC stage and increase receipt of surgery, Hispanic ethnicity was an independent predictor of worse outcome. Further work is necessary to confirm this health disparity in other large datasets. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e961-e962 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Alfredo Suarez-Sarmiento More articles by this author Brian Shuch More articles by this author Cayce Nawaf More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Are appendectomy outcomes in level I trauma centers as good as we think?

BackgroundDesignated trauma centers improve outcomes for severely injured patients. However, major trauma workload can disrupt other care pathways and some patient groups may compete ineffectively for resources with higher priority trauma cases. This study tested the hypothesis that treatment at a higher-level trauma center is an independent predictor for worse outcome after appendectomy. MethodsAn observational study was undertaken using an all-payer longitudinal data set (California State Inpatient Database 2007–2011). All patients with an ICD-90-CM diagnosis of “acute appendicitis” (International Classification of Diseases, Ninth Revision, Clinical Modification code 540) that subsequently underwent appendectomy were included. Patients transferred between hospitals were excluded to minimize selection bias. The outcome measures were days to the operating room, length of stay, unplanned 30-d readmission (to any hospital in California), and in-hospital mortality. Logistic and generalized linear regression models were used to adjust for patient- (age, sex, payer status, race, Charlson comorbidity index, weekend admission, and generalized peritonitis) and hospital-level (teaching status and bed size) factors. ResultsThere were 119,601 patients treated in 278 individual hospitals. Patients in level I trauma centers (L1TCs) reached the operating room later (predicted mean difference 0.25 d [95% confidence interval 0.14–0.36]), stayed in hospital longer (0.83 d [0.36–1.31]), and had higher adjusted odds of generalized peritonitis (odds ratio 1.63 [95% confidence interval 1.13–2.36]) than those in nontrauma centers. There were no differences in mortality or unplanned 30-d readmissions to hospital; or between level II trauma centers and nontrauma centers across any of the measured outcomes. ConclusionsOdds of generalized peritonitis are higher and hospital length of stay is longer in L1TCs, although we found no evidence that patients come to serious harm in such institutions. Further work is necessary to determine whether pressure for resources in L1TCs can explain these findings.

TH and DCX mRNAs in peripheral blood and bone marrow predict outcome in metastatic neuroblastoma patients.

In metastatic neuroblastoma (NB) patients, accurate risk stratification and disease monitoring would reduce relapse probabilities. This study aims to evaluate the independent prognostic significance of detecting tyrosine hydroxylase (TH) and doublecortin (DCX) mRNAs by reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) in peripheral blood (PB) and bone marrow (BM) samples from metastatic NB patients. RT-qPCR was performed on PB and BM samples from metastatic NB patients at diagnosis, post-induction therapy and at the end of treatment for TH and DCX mRNAs detection. High levels of TH and DCX mRNAs when detected in PB and BM at diagnosis independently predicted worse outcome in a cohort of 162 metastatic NB. In the subgroup of high-risk metastatic NB, TH mRNA detected in PB remained as independent predictor of EFS and OS at diagnosis. After the induction therapy, high levels of TH mRNA in PB and DCX mRNA in BM independently predicted poor EFS and OS. Furthermore TH mRNA when detected in BM predicted worse EFS. TH mRNA in PB samples at the end of treatment is an independent predictor of worse outcome. TH and DCX mRNAs levels in PB and BM assessed by RT-qPCR should be considered in new pre-treatment risk stratification strategies to reliable estimate outcome differences in metastatic NB patients. In those high-risk metastatic NB, TH and DCX mRNA quantification could be used for the assessment of response to treatment and for early detection of progressive disease or relapses.

Concurrent Preoperative Presence of Hydronephrosis and Flank Pain Independently Predicts Worse Outcome of Upper Tract Urothelial Carcinoma.

ObjectivesTo investigate the impact of preoperative hydronephrosis and flank pain on prognosis of patients with upper tract urothelial carcinoma.MethodsIn total, 472 patients with upper tract urothelial carcinoma managed by radical nephroureterectomy were included from Kaohsiung Medical University Hospital Healthcare System. Clinicopathological data were collected retrospectively for analysis. The significance of hydronephrosis, especially when combined with flank pain, and other relevant factors on overall and cancer-specific survival were evaluated.ResultsOf the 472 patients, 292 (62%) had preoperative hydronephrosis and 121 (26%) presented with flank pain. Preoperative hydronephrosis was significantly associated with age, hematuria, flank pain, tumor location, and pathological tumor stage. Concurrent presence of hydronephrosis and flank pain was a significant predictor of non-organ-confined disease (multivariate-adjusted hazard ratio = 2.10, P = 0.025). Kaplan-Meier analysis showed significantly poorer overall and cancer-specific survival in patients with preoperative hydronephrosis (P = 0.005 and P = 0.026, respectively) and in patients with flank pain (P < 0.001 and P = 0.001, respectively) than those without. However, only simultaneous hydronephrosis and flank pain independently predicted adverse outcome (hazard ratio = 1.98, P = 0.016 for overall survival and hazard ratio = 1.87, P = 0.036 for and cancer-specific survival, respectively) in multivariate Cox proportional hazards models. In addition, concurrent presence of hydronephrosis and flank pain was also significantly predictive of worse survival in patient with high grade or muscle-invasive disease. Notably, there was no difference in survival between patients with hydronephrosis but devoid of flank pain and those without hydronephrosis.ConclusionConcurrent preoperative presence of hydronephrosis and flank pain predicted non-organ-confined status of upper tract urothelial carcinoma. When accompanied with flank pain, hydronephrosis represented an independent predictor for worse outcome in patients with upper tract urothelial carcinoma.

Red cell transfusion in the critically ill patient

It has been more than a decade since the TRICC trial established the concept of restrictive transfusion. The CRIT study subsequently showed that RBC transfusion may be an independent predictor of worse outcome. We undertook an audit to determine how our practice compares to the current evidence.