Risk Factors For Unfavorable Outcome Research Articles

Influence of patient's age on the clinical presentation, morbidity, and mortality in COVID-19: A brief review

Currently, COVID-19 is spreading rapidly and presenting with different clinical features with different mortality rates worldwide. In the initial days of the pandemic, most of the patients presented with the complaints of lower respiratory tract infection of varying severity, and most of the deaths were also attributable to respiratory failure. As time progressed, more atypical presentations and causes of mortality were encountered according to different age groups. In the present scenario, a surge of COVID-19 cases is expected. Those new cases will also include patients with various problems requiring surgical interventions. In this brief review, we have discussed various presentations and mortality risks of COVID-19 infections in different age groups. We did literature searched on the PubMed database and included studies published in 2019 and 2020. Altogether, 503 articles were retrieved out of which 31 were analyzed to put up this summary. Important atypical findings in neonates and infants were axial hypotonia, drowsiness, moaning sound, intussusception, and late-onset neonatal sepsis with the cause of death being multi-organ failure. Frequently reported comorbidities among children were hydronephrosis, leukemia, and intussusception. Observed risk factors for unfavorable outcome in the adult population were obesity, HIV, tuberculosis, and the intake of immunosuppressive agents in the form of anticancer drugs and steroids. The factors adding to the vulnerability in the elderly population could be enumerated as diabetes, hypertension, ischemic heart diseases, obesity, and cancers.

Prediction of renal outcome in Henoch\u2013Sch\xf6nlein nephritis based on biopsy findings

BackgroundIn Henoch–Schönlein nephritis (HSN), a risk factor for unfavorable outcome is prolonged proteinuria, but the value of renal biopsies in prognosis assessment is debatable.MethodsWe evaluated serial renal biopsies from 26 HSN patients. Follow-up biopsy occurred at median 2.1 years after diagnostic biopsy. Patients formed two groups at the follow-up biopsy: patients without proteinuria (group I; n = 11) and with proteinuria (group II; n = 15). Biopsies underwent evaluation according to three classifications: International Study of Kidney Disease in Children (ISKDC), Oxford (MEST-C), and semiquantitative classification (SQC) including an activity and chronicity score. Analysis also included expression of pro-fibrotic (alpha-smooth muscle actin and vimentin) and inflammatory (P-selectin glycoprotein ligand-1) molecules in the diagnostic biopsy specimens. Definition of unfavorable outcome was active renal disease or reduced renal function at last follow-up.ResultsBetween the biopsies, SQC chronicity score increased in 22 (85%) patients, whereas activity score and ISKDC grade decreased in 21 (81%) and 17 (65%), respectively. Of the MEST-C parameters, endocapillary proliferation (from 83 to 13%; p < 0.001) and crescents (from 63 to 25%; p = 0.022) showed significant reduction, and segmental glomerulosclerosis (from 38 to 79%; p = 0.006) significant increment. These changes occurred similarly in groups I and II. Expression of the pro-fibrotic and inflammatory molecules showed no clinically significant differences between groups I and II. None in group I and five (33%) patients in group II had unfavorable outcome (p = 0.053).ConclusionsOur results suggest that follow-up biopsies provide limited additional information to clinical symptoms in HSN outcome prediction.

Courbes de survie à plus de 10 ans des prothèses trapézo-métacarpiennes: à propos de 294 cas

Thumb carpometacarpal osteoarthritis affects many post-menopausal women. If medical treatment fails, the most common options are trapeziectomy and trapezio-metacarpal arthroplasty. The purpose of this study was to evaluate the survival rate of trapezio-metacarpal prostheses in surgical treatment of thumb carpometacarpal osteoarthritis, and to highlight potential risk factors of unfavorable outcome. We performed a retrospective study involving 294 trapezio-metacarpal prostheses in 245 patients, who underwent surgery between 2001 and 2016. Clinical assessment was performed by self-questionnaire including pain, satisfaction, recovery time, QuickDASH Score, and opposition according to Kapandji score. Thumb X-rays were used to evaluate implant loosening sign, periprosthetic remodeling, and arthrosis of over and underlying joints. Implants survival rate at the final follow-up of 17.3 years was 90.8 % (95 % CI [85.8–96.1]). Median pain was 1 on 10 on VAS scale (0–8). Median QuickDASH Score was 20 (0–82), median opposition according to Kapandji was 9 on 10 (3–10). Median return to work time was 2 months (1–12). We identified 7.8 % of major complications, including 3.4 % of dislocations, 3.1 % of implants loosening, and 1 % of fractures. All dislocations involved surgical revision. Only few publications show results with more than 100 trapezio-metacarpal prostheses. Our results are consistent with existing studies. Trapeziectomy represents currently the gold standard in surgical treatment of thumb carpometacarpal osteoarthritis. Long-term superiority has not been proven in recent meta-analysis. Two recent studies found superiority of arthroplasty at short term concerning pain, strength, mobility, satisfaction, and recovery time, with similar complication rates. Trapezio-metacarpal arthroplasty is a long-term reliable solution for surgical treatment of thumb carpometacarpal osteoarthritis, with a limited complication rate.

222. Bloodstream Infections by Gram(−) Bacteria in Kidney Transplant Patients: Risk Factors, Incidence and Outcome; Bloodstream Infections by Gram(−) Bacteria in Kidney Transplant Patients: Risk Factors, Incidence and Outcome

BackgroundKidney transplant recipients are at increased risk for infections. The aims of this study were: i) to estimate the incidence of bloodstream infections (BSI) caused by Gram(−) bacteria in kidney transplant recipients, ii) to identify risk factors for BSI by multidrug-resistant Gram(−) bacteria, and iii) to identify predictors for outcome (death/loss of transplanted kidney).MethodsWe conducted a retrospective cohort study at the renal transplant unit (RTU) of a tertiary care hospital located in Athens, Greece, between September 2008 and September 2018. Kidney transplant recipients with Gram(−) BSIs were identified from the microbiology laboratory electronic records. Patient-, infection-, and treatment-related factors were extracted from the medical records. Species identification and susceptibility testing were performed by MicroScan automated system. The statistical analysis was performed using IBM SPSS Statistics v20.ResultsDuring the study period, 1962 kidney transplant patients were followed at our RTU. A total of 195 BSI episodes were recorded in 182 patients (male/female=97/85), with median (25th, 75th) age 57.2 (44, 64.9) years. The incidence of BSI was 1.393/100 patient-years. Median (25th, 75th) time interval between transplantation date and onset of BSI was 67.67 (8.3, 148) months. Escherichia coli was the most common cause (64.3%, 117/182), while the most common source of infection was urinary tract (70.9%, 129/182). 19.2% (53/182) of BSIs were caused by multidrug-resistant organisms (MDR). 6% (11/182) of patients died and 2.2% (4/182) were subjected to nephrectomy. Multivariate logistic regression showed that diabetes mellitus (odds ratio [OR] 7.714; 95% confidence interval [CI] 1.311–45.385), Pseudomonas aeruginosa BSI (OR 35.788; CI 3.3–388.182) and septic shock (OR 74.468; CI 3.513–1578.513) were predictors of an unfavorable outcome. Previous antibiotic use (OR 11.964; CI 2.686–53.293) and previous stay in Intensive Care Unit (OR 18.055; CI 1.046–311.536) were associated with MDR BSIs.ConclusionBSIs in kidney transplant recipients is a critical factor of morbidity and mortality. Recognizing the risk factors for unfavorable outcome and emergence of MDR bacteria could offer a significant advantage in early diagnosis and appropriate treatment.Disclosures All authors: No reported disclosures.

Past history of stage I/II solid tumor malignancy impacts considerably on sepsis mortality: a propensity score matching analysis from the hellenic sepsis study group

BackgroundWhether past history of solid stage I/II inactive cancer has an impact on 28-day mortality of sepsis remains unclear. We aimed to determine the impact of history of stage I or II solid tumor malignancy in complete remission the last 3 years on sepsis outcome.MethodsUsing the database of the Hellenic Sepsis Study Group from 1553 patients with sepsis admitted in the ICU, 83 patients with sepsis by Sepsis-3 definition with past-history of stage I/II inactive solid malignancy the last 3 years were depicted. A comparator group of 83 patients fully matched for age, severity, type of infection and comorbidities was selected by propensity score matching.ResultsMortality after 28 days was 37.3% in the comparator group and 54.2% in the solid tumor stage I/II group (odds ratio for death 1.98; p: 0.030). Following step-wise forward Cox regression analysis, septic shock (hazard ratio 1.80), acute renal injury (hazard ratio 2.06), history of coronary heart disease (hazard ratio 0.36) and history of stage I/II solid tumor malignancy (hazard ratio 1.79) were the only independent variables associated with 28-day mortality. Serum levels of procalcitonin and of soluble urokinase plasminogen activator receptor were similar between the two groups of comparisons.ConclusionsPast history of stage I/II solid malignancy is an independent risk factor for unfavorable outcome from sepsis the first 28 days.

Risk Factors of Unfavorable Outcome in Children with Mitral Valve Repair

espanolAnalizar los factores de riesgo de evolucion desfavorable (ED) en ninos con insuficiencia mitral (IM) sometidos a plastica mitral (PM). Metodos: Se analizaron pacientes con IM sometidos a PM entre el 2004 al 2014. Se definio ED como reoperacion o IM significativa (moderada a severa (3+) o severa (4+)) durante el seguimiento. Las variables se expresaron como mediana. Se realizo analisis multivariado de regresion logistica de los factores predictores de ED. Resultados. Sesenta y cinco pacientes con IM3+ y IM4+ se sometieron a PM. La etiologia fue: displasia 44,6%, endocarditis infecciosa 13,8%, fiebre reumatica 18,4%, anomalia coronaria 7,7%, otros 13,8%. La mediana del seguimiento fue 26,5 meses. 44,6% presentaron disfuncion ventricular y el 46,1% hipertension pulmonar. 52 pacientes se encuentran en seguimiento. Quince presentaron ED: 9 fueron reoperados (7 reemplazos valvulares y 2 re-plastica). El analisis univariado demostro asociacion significativa entre ED y: fiebre reumatica (p0.005), anillo mitral preoperatorio ≥+5DS (p0.002), diametro sistolico del ventriculo izquierdo (DSVI) ≥+4DS (p0.022), hipertension pulmonar (p0. 024) y la IM residual postoperatoria inmediata ≥ moderada (p0.021). El analisis multivariado demostro como variables independientes de ED: diametro del anillo mitral (p0.012), fiebre reumatica (p0.026) y la IM residual temprana (p0.042). No se produjo mortalidad. Conclusiones. La plastica mitral en ninos con IM severa demostro resultados favorables a mediano plazo. La fiebre reumatica, el diametro del anillo mitral ≥+5DS y la IM residual ≥2 + fueron factores predictores de ED. Ni la edad, ni la disfuncion ventricular mostraron diferencias estadisticamente significativas durante el seguimiento. EnglishThe aim of this study was to analyze risk factors of unfavorable outcome (UO) in patients with mitral regurgitation(MR) undergoing mitral valve repair (MVR).Methods: Patients with MR who had undergone MVR from 2004 to 2014 were retrospectively analyzed. Unfavorable outcomewas defined as reoperation or significant MR [moderate to severe (3+) or severe MR (4+)] during follow-up. Variables wereexpressed as median. Univariate and multivariate logistic regression analyses were performed to identify predictive factorsof UO.Results: Sixty five patients with MR3+ and MR4+ underwent MVR. Etiology was dysplasia in 44.6% of cases, infective endocarditisin 13.8%, rheumatic fever in 18.4%, abnormal coronary origin in 7.7% and other disorders in 13.8%. Median follow-uptime was 26.5 months (52 patients are still being followed-up).Ventricular dysfunction was documented in 44.6% of casesand 46.1% had pulmonary hypertension. Fifteen patients presented UO and 9 were reoperated (7 valve replacements and 2re-repairs). Univariate analysis demonstrated a significant association between UO and the following conditions: rheumaticfever (p=0.005), preoperative mitral annulus ≥+5 SD (p=0.002), left ventricular end-systolic diameter ≥+4 SD (p=0.022),pulmonary hypertension (p=0.024) and immediate postoperative residual MR ≥ moderate (p=0.021). Multivariate analysisdemonstrated mitral annulus diameter (p=0.012), rheumatic fever (p=0.026) and early residual MR (p=0.042) as independentvariables of UO. No deaths occurred in this series.Conclusions: Mitral valve repair in children with severe MR demonstrated mid-term favourable results. Rheumatic fever,mitral annulus diameter ≥+5 SD and immediate postoperative residual MR ≥2+ were predictive factors of UO. Neither ageat surgery nor ventricular dysfunction showed statistically significant differences during follow-up.

Gaps in tuberculosis care in West Sepik Province of Papua New Guinea.

Papua New Guinea (PNG), a low-resource country with a high tuberculosis (TB) burden. To describe the characteristics, treatment outcomes and risk factors for unfavourable outcomes among patients registered for first-line tuberculosis (TB) treatment between 1 January 2014 and 31 December 2016 in West Sepik Province. This was a retrospective cohort study of routinely collected programme data. Of 1058 cases, 50.7% were male and 38.8% were aged <15 years; 43.1% were extrapulmonary TB cases and 280 (26.5%) were bacteriologically confirmed. No human immunodeficiency virus (HIV) status was recorded for 74.7% of cases. Of 1019 (96.3%) patients with a recorded outcome, 779 (76.4%) were favourable and 240 (23.6%) were unfavourable. On multivariable logistic regression, increasing age was associated with an increased odds of an unfavourable outcome (adjusted OR [aOR] 1.06 per every 5-year increase, 95%CI 1.02-1.11; P = 0.006) and being a retreatment case was associated with a reduced odds of an unfavourable outcome compared to new cases (aOR 0.54, 95%CI 0.31-0.93; P = 0.027). This study identified substantial gaps in TB care, including low rates of bacteriological diagnosis and HIV testing, and high rates of loss to follow-up, highlighting the need to strengthen TB control efforts, including support for new cases.

Predictors for Pulmonary Tuberculosis Treatment Outcome in Denmark 2009\u20132014

Monitoring of tuberculosis (TB) treatment outcome is essential to ensure an effective TB control program. In this nationwide retrospective cohort study from Denmark we present TB treatment outcome rates and risk factors associated with an unfavourable outcome. All patients notified with pulmonary TB from 2009 through 2014 were included. Logistic regression analyses were used to identify risk factors for unfavourable outcome. In total, 1681 pulmonary TB cases were included. TB treatment success rates increased during the study period. In 2014, the treatment success rate reached 85% for new culture positive cases whereas 7% cases interrupted treatment. The mortality decreased during the study period from 12.3% to 4.1%. Several risk factors associated with unfavourable outcome were identified in a multivariable model: male (OR: 2.56), Greenlandic origin (OR: 1.80), abuse of alcohol (OR: 2.90), history of mental disorder (OR: 2.46), and anaemia at time of treatment initiation (OR: 1.92). In a TB low incidence setting such as the Danish, it is important to maintain focus on preventing an unfavourable TB outcome. Patient management and treatment can be optimized by taking into consideration risk factors such as those identified in the present study.

Extrapulmonary Tuberculosis in Denmark From 2009 to 2014; Characteristics and Predictors for Treatment Outcome.

BackgroundExtrapulmonary tuberculosis (EPTB) represents an increasing percentage of tuberculosis (TB) cases in Europe. However, strategies on TB prevention and successful treatment outcomes primarily target pulmonary TB. In this nationwide study, we present characteristics of EPTB, treatment outcomes, and predictors for unfavorable treatment outcomes.MethodsAll patients diagnosed with EPTB from 2009 to 2014 were included. Logistic regression analyses were used to identify risk factors for unfavorable outcome. The following definitions were used: unfavorable outcome: the sum of treatment failed, lost to follow-up, and not evaluated; patient delay: time from TB-related symptom onset until first hospital contact related to TB; doctor delay: time from first TB-related contact in the health care system to start of TB treatment.ResultsA total of 450 EPTB cases were notified, which represented 21.1% of all TB cases in Denmark. Immigrants accounted for 82.9%. Lymph nodes were the most common site of EPTB (55.4%) followed by pleural TB (13.4%). Patient delay was significantly longer among immigrants than Danes (60 vs 30 days; P < .01), whereas doctor delay was significantly longer among Danes (38.5 vs 28 days; P < .01). Treatment completion rates were high and reached 90.9% in 2014. Male gender (odds ratio [OR], 5.18; 95% confidence interval [CI], 1.79–15.04) and age 0–24 years (OR, 16.39; 95% CI, 2.02–132.64) were significantly associated with unfavorable outcome.ConclusionsEPTB represented a significant number of all TB cases and was predominantly seen among younger immigrants in Denmark. To maintain high treatment completion rates, increased focus on male gender and young age is needed.

External validation of the TRISS, CRASH, and IMPACT prognostic models in severe traumatic brain injury in Japan.

In Japan, a range of patients with traumatic brain injury (TBI) has been recorded in a nationwide database (Japan Neurotrauma Data Bank; JNTDB). This study aimed to externally validate three international prediction models using JNTDB data: Trauma and Injury Severity Score (TRISS), Corticosteroid Randomization After Significant Head Injury (CRASH), and International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT). We also aimed to validate the applicability of these models in the Japanese population. Of 1,091 patients registered in the JNTDB from July 2009 to June 2011, we analyzed data for 635 patients. We examined factors associated with mortality in-hospital and unfavorable outcomes 6 months after TBI by applying the TRISS, CRASH, and IMPACT models. We also conducted an external validation of these models based on these data. The patients’ mean age was 60.1 ±21.1 years, and 342 were alive at the time of discharge (53.9%). Univariate analysis revealed eight major risk factors for mortality in-hospital: age, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), systolic blood pressure, heart rate, mydriasis, acute epidural hematoma (AEDH), and traumatic subarachnoid hemorrhage. A similar analysis identified five risk factors for unfavorable outcomes at 6 months: age, GCS, ISS, mydriasis, and AEDH. For mortality in-hospital, the TRISS had a satisfactory area under the curve value (0.75). For unfavorable outcomes at 6 months, the CRASH (basic and computed tomography) and IMPACT (core and core extended) models had satisfactory area under the curve values (0.86, 0.86, 0.81, and 0.85, respectively). The TRISS, CRASH, and IMPACT models were suitable for application to the JNTDB population, indicating these models had high value in Japanese patients with neurotrauma.

The Association between FLAIR Vascular Hyperintensity and Stroke Outcome Varies with Time from Onset

FLAIR vascular hyperintensity has been recognized as a marker of collaterals in ischemic stroke, but the impact on outcome is still controversial. We hypothesized that the association between FLAIR vascular hyperintensity and outcome varies with time. We included 459 consecutive patients with middle cerebral artery stroke and divided them into 3 groups by symptom-to-MR imaging time (group 1, ≤7 days; group 2, 8-14 days; group 3, ≥15 days). The FLAIR vascular hyperintensity score, ranging from 0 to 3 points, was based on territory distributions of different MCA segments. The associations between FLAIR vascular hyperintensity and outcome with time were analyzed qualitatively and quantitatively. No patients underwent MR imaging within 6 hours of onset. The proportion of FLAIR vascular hyperintensity (+) and severe stenosis or occlusion of MCA was not significantly dependent on time. In groups 1 and 2, FLAIR vascular hyperintensity (+) was significantly associated with larger lesions, the prevalence of flow injury, and unfavorable outcome (mRS ≥ 2). There were no such associations in group 3. Multiple logistic regressions demonstrated that FLAIR vascular hyperintensity (+) was an independent risk factor for unfavorable outcome in group 2. Infarction volume tended to increase with the increase of the distal FLAIR vascular hyperintensity score in groups 1 and 2, while declining in group 3. FLAIR vascular hyperintensity is associated with unfavorable outcome within 6 hours to 14 days of onset, while the wider distribution of distal FLAIR vascular hyperintensity may be favorable beyond 14 days of onset in MCA infarction. Symptom-to-MR imaging time should be considered when assessing the prognostic value of FLAIR vascular hyperintensity.

Association between Non-Alcoholic Fatty Liver Disease and Intracerebral Hemorrhage

To determine whether non-alcoholic fatty liver disease (NAFLD) and intracerebral hemorrhage (ICH) are connected, and assess the role played by NAFLD in ICH development. A retrospective study evaluated inpatients treated at the First Affiliated Hospital of Zhejiang University. We divided the patients into Group A (ICH with NAFLD) and Group B (ICH alone). Moreover, univariate and multivariate logistic regression analyses were performed to identify the risk factors for unfavorable outcomes. A total of 128 patients were included: 34 ICH with NAFLD (group A) and 94 ICH (group B). Sixteen patients exhibited an unfavorable outcome. There was no significant difference among the two groups on the underlying diseases hypertension and heart disease. Group A had more diabetes mellitus cases (35.29% vs 12.76%, p = 0.004). Levels of alanine aminotransferase and triglyceride were higher in group A than in group B (all p < 0.05), while differences in other blood biochemistry tests were statistically insignificant (all p > 0.05). There was a similarity in bleeding sites except for brainstem hemorrhage, which was higher in group B patients (p = 0.036). Multivariate logistic regression analysis revealed that low-density lipoprotein (OR, 0.278; 95% CI (0.107–0.702), p = 0.008) was a protective factor for ICH patients with NAFLD. The National Institute of Health Stroke Scale (NIHSS) score at discharge (OR, 3.152; 95% CI (1.532–6.486), p = 0.002) was independent of risk factors for unfavorable outcomes. Serum levels of LDL was a protective factor. NAFLD did not increase the unfavorable outcome of ICH patients in our study.

Outcomes and risk factors of massive and submassive pulmonary embolism in children: a retrospective cohort study

Little is known about severe pulmonary embolism in children. We aimed to report pulmonary embolism outcomes, identify risk factors for unfavourable outcomes, and evaluate the discriminative ability of two clinical-severity indices in children. In this retrospective cohort study, we included consecutive patients aged 18 years or younger with acute pulmonary embolism, objectively diagnosed radiologically or pathologically, between Jan 1, 2000, and Dec 31, 2016, from two Canadian paediatric hospitals (The Hospital for Sick Children, Toronto, ON, and the Children's Hospital of Eastern Ontario, Ottawa, ON). Exclusion criteria were sudden death without radiological or pathological pulmonary embolism confirmation and non-thromboembolic pulmonary embolism. The primary outcome was a composite of unfavourable outcomes of pulmonary embolism-related death and pulmonary embolism recurrence or progression. Potential predictors of the composite unfavourable outcome (ie, age at pulmonary embolism diagnosis, sex, underlying cardiac disease, severity of the pulmonary embolism, presence of a central venous catheter, associated venous thromboembolism, family history of thrombosis, treatment modalities, thrombophilia, obesity, and recent surgery) were explored with logistic regression. We calculated pulmonary embolism severity index (PESI) and simplified PESI (sPESI) using age-adjusted parameters; we estimated the ability of PESI and sPESI to predict mortality using receiver-operating characteristic (ROC) curve analysis. Of the 170 patients included, 37 (22%) had massive, 12 (7%) submassive, and 121 (71%) non-massive pulmonary embolism. Patients with massive or submassive pulmonary embolism were younger (median age 12·5 years [IQR 0·6-15·1] vs 14·4 years [9·3-16·1], p<0·0001), more likely to have a cardiac condition (16 [33%] vs 17 [14%] patients, p=0·009), and had more central venous catheters (29 [59%] vs 48 [40%] patients, p=0·027) than patients with non-massive pulmonary embolism. Aggressive treatment modalities were more commonly used in massive or submassive pulmonary embolism (22 [45%] vs 7 [6%] patients, p<0·0001). Of the predictors tested, only pulmonary embolism severity was associated with the composite unfavourable outcome in the multivariable analysis (odds ratio 3·53, 95% CI 1·69-7·36; p=0·011). The area under the ROC curve for PESI to predict 30-day mortality was 0·76 (95% CI 0·64-0·87). Sensitivity of sPESI was 100% and specificity was 30%. Massive or submassive pulmonary embolism led to higher rates of unfavourable outcomes than non-massive pulmonary embolism in children. Further adaptations of PESI and sPESI are required to improve their clinical usefulness in paediatric patients. Trainee Start-Up Fund (The Hospital for Sick Children).

Posterior reversible encephalopathy syndrome.

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by acute cerebral endotheliopathy with consecutive disruption of the blood-brain barrier and vasogenic edema. Since its first description in 1996, PRES is increasingly recognized. However, many aspects of this syndrome with its wide spectrum of clinical and radiological features are still incompletely understood. In this review, possible pathophysiological mechanisms, approaches to diagnosis, recent study results on outcome, and future directions of research are described. Clinical manifestations of PRES include seizures, headache, visual disturbances, altered mental state, and more rarely hemiparesis or aphasia. Vasogenic edema predominantly occurs in the parieto-occipital region, but lesions affecting formerly called 'atypical' regions such as frontal lobe, cerebellum, or basal ganglia are common. If treated early and adequately, that is by removal of the underlying cause, PRES has a favorable prognosis, but neurological residual symptoms and even mortality can occur, particularly in patients with complications such as intracranial hemorrhage. In summary, validated diagnostic criteria and algorithms are warranted to standardize the diagnosis of PRES. This is essential for further research and future prospective studies that should investigate risk factors for unfavorable outcome and identify the roles of imaging features, clinical symptoms, and other biomarkers in predicting outcome.

Treatment Strategy for Unruptured Intracranial Aneurysm in Elderly Patients: Coiling, Clipping, or Conservative?

An increasing number of unruptured intracranial aneurysms (UIAs) has been discovered in elderly patients in recent years, but the optimal treatment strategy for these patients remains controversial. We report our six-year experience treating UIAs in elderly patients (≥ 70 years old). A retrospective review was conducted of elderly patients who harbored UIAs treated by conservative observation, microsurgical clipping, or endovascular coiling between January 2009 and December 2014. The patients’ clinical and imaging information was recorded. Treating methods, procedure-related complications, imaging results, and clinical outcomes were analyzed. A total of 141 consecutive elderly patients with 166 UIAs were enrolled in our study. In all, 64 patients with 79 aneurysms were treated with coiling, and 14 patients with 14 aneurysms were treated with clipping. The remaining 63 patients with 73 aneurysms were placed under conservative observation. The average modified Rankin scale was 0.99 (range 0–6) in the full cohort after a mean follow-up of 50.4 months (range 0–70 months). There was no significant difference of modified Rankin scale in patients with UIAs treated by different methods. Multivariate analysis showed that age (p=0.030) and aneurysm size (p=0.011) were independent risk factors for unfavorable outcome of UIAs in the elderly. Patient age (p=0.010) and aneurysm size (p=0.020) were also significantly associated with unfavorable outcome of UIAs managed with observation initially. Our results indicated that endovascular coil embolization and clipping were both safe and effective treatment methods for UIAs in the elderly. Aggressive treatment for UIAs in elderly patients with risk factors of aneurysm rupture should be considered positively.

Факторы риска неблагоприятного исхода заболевания у пациентов с ВИЧ-ассоциированным туберкулезом

Факторы риска неблагоприятного исхода заболевания у пациентов с ВИЧ-ассоциированным туберкулезом

Acute Traumatic Compartment Syndrome of the Forearm: Literature Review and Unfavorable Outcomes Risk Analysis of Fasciotomy Treatment.

Forearm compartment syndrome is a relatively underreported event compared with compartment syndrome of the lower extremity or trunk. The aim of this review of the literature was to provide insight into the potential consequences of certain treatment modalities in the control of acute compartment syndrome of the forearm based on data presented over the past 44 years. A comprehensive search was conducted across several databases including EMBASE, Ovid MEDLINE, Cochrane Database of Systematic Reviews, and Scopus, capturing studies published from 1973 to 2017 to identify potential articles for inclusion in the review. Outcomes data were evaluated for each of the studies included in this analysis on the basis of treatment utilized (fasciotomy vs. no fasciotomy) and respective outcome (favorable vs. unfavorable). Relative risk (RR) analysis was performed to determine risk factors for unfavorable outcomes from the pooled data. The analysis revealed a statistically significant higher likelihood of unfavorable outcomes resulting from performing fasciotomy in the event of forearm compartment syndrome compared with conservative management (RR = 4.82, p < .01). Fasciotomy treatment was associated with a higher likelihood of patients presenting with forearm compartment syndrome to experience unfavorable outcomes. The results of this study can help guide awareness of potential sequelae of treatment choices in forearm compartment syndrome, and clinical decision-making for wise patient selection for surgical intervention, when necessary.

A Study on Prevalence of Anaemia in Pregnancy among the Women Reporting for Antenatal Care in Combined Military Hospital, Dhaka Cantonment

Background: Anemia is regarded as a major risk factor for unfavorable outcome of pregnancy both for the mother and the fetus. Maternal anaemia is a common problem in pregnancy, particularly in developing countries.Aims: To determine the prevalence of anaemia in pregnancy and to find out the haemoglobin level of pregnant women reporting for antenatal checkup among the women reporting for antenatal care in Combined Military Hospital Dhaka.Method: This is a descriptive cross sectional study was done in the antenatal clinic at CMH Dhaka. One eighty four (184) pregnant women attending antenatal clinic at CMH Dhaka including CWC under CMH Dhaka were included for the study. The data were collected from 1st May 2001 to 31st May 2001 at the antenatal clinic, combined Military Hospital. Dhaka where pregnant women reported for antenatal check up. The data were collected by interviewing respondents in different dates &amp; day of the week at different CWC and CMI-I Dhaka. Prior to the interview the respondents were explained clearly the objective of the study and sought their co-operation. The authority of CMH Dhaka was given prior information through issuing letter from AFMI. The respondent was assured on ethical point of view that strict secrecy would be maintained. Data were collected by the following methods: Interview Method; Laboratory Investigation for Hb estimation and Scrutinization of antenatal check up card.Results: A total of 184 pregnant women of them 70 were primi gravida and 114 were multigravida. The prevalence of anaemia as per WHO cutoff points was 56.52% (&lt;11.0 g/dl). The mean age was 24.96 ± 4.49 years. The age groups 20-24 was the maximum. Out of 184 women 104 women was ariaemic. 15-24 age group was more anaemic (57.42%) than the 25-39 age group (55.42%) but the difference was not statistically significant, P&gt;0.05. The prevalence of anaemia was higher in Illiterate (100%), lowest in degree and above level education group (48.48%). The maximum women (64.13%) belong to lowest income group. (Tk 2500-5000) Anaemia was the most common in the lowest income group (60.50%). The prevalence of anaemia was the highest among the family size 6 and above group (75%) and lowest in 2-3 family size group. Anaemia was more prevalent among high parity group (75%) and lowest in ‘0’ parity group (52.28%) but the difference was not statistically significant (P &gt; 0.05). Multigravida were found more anaemic (62.28%) contrast to prirnigravida (47.14%) which was statistically significant (P&lt;0.05). The prevalence of anaemia was less in higher birth interval group but the difference was not statistically significant (P&gt;0.05). About the cultural belief only 33 women were found having cultural belief of avoiding food during pregnancy (17.93%) and anaemia was more prevalent among them (57.57%) but the difference was statistically significant (P&gt;.05). In this study 14.13% women had concomitant illness during pregnancy. In this study 15 women had caesarian section of which 10 were anaemic (75%) and there was one Forcep delivery (non-anaemic).Conclusion: In this study anaemia is more prevalent among younger age group women (15-24), with less educated group low income group, large family size group, high parity and high gravida, less birth spacing and also in women having concomitant illness. Anaemia is more prevalent among women having cultural belief on avoiding food during pregnancy. The findings of this study may not reflect the overall picture of the country. It does not differ much from the results of similar studies at national level. However, this study can be a base for further studies in a broader perspective.J Dhaka Medical College, Vol. 26, No.2, October, 2017, Page 103-110

A patient-level pooled analysis of treatment-shortening regimens for drug-susceptible pulmonary tuberculosis

Tuberculosis kills more people than any other infectious disease. Three pivotal trials testing 4-month regimens failed to meet non-inferiority margins; however, approximately four-fifths of participants were cured. Through a pooled analysis of patient-level data with external validation, we identify populations eligible for 4-month treatment, define phenotypes that are hard to treat and evaluate the impact of adherence and dosing strategy on outcomes. In 3,405 participants included in analyses, baseline smear grade of 3+ relative to <2+, HIV seropositivity and adherence of ≤90% were significant risk factors for unfavorable outcome. Four-month regimens were non-inferior in participants with minimal disease defined by <2+ sputum smear grade or non-cavitary disease. A hard-to-treat phenotype, defined by high smear grades and cavitation, may require durations >6 months to cure all. Regimen duration can be selected in order to improve outcomes, providing a stratified medicine approach as an alternative to the ‘one-size-fits-all’ treatment currently used worldwide.

Model of care and risk factors for poor outcomes in patients on multi-drug resistant tuberculosis treatment at two facilities in eSwatini (formerly Swaziland), 2011-2013.

IntroductionSince 2011 Médecins sans Frontières together with the eSwatini Ministry of Health have been managing patients with multi-drug resistant tuberculosis (MDR-TB) at Matsapha and Mankayane in Manzini region. This analysis describes the model of care and outcomes of patients receiving a 20 months MDR-TB treatment regimen between 2011 and 2013.MethodWe conducted a retrospective observational cohort study of MDR-TB patients enrolled for treatment between May 2011 and December 2013. An extensive package of psychological care and socio-economic incentives were provided including psychological support, paid treatment supporters, transport fees and a monthly food package. Baseline demographic details and treatment outcomes were recorded and for HIV positive patient’s univariate analysis as well as a cox regression hazard model were undertaken to assess risk factors for unfavorable outcomes.ResultsFrom the 174 patients enrolled, 156 (89.7%) were HIV co-infected, 102 (58.6%) were female, median age 33 years old (IQR: 28–42), 55 (31.6%) had a BMI less than 18 and 86 (49.4%) had not been previously treated for any form of TB. Overall cohort outcomes revealed a 75.3% treatment success rate, 21.3% mortality rate, 0.6% failure and 0.6% lost to follow-up rate. In the adjusted multivariate analysis, low BMI and low CD4 count at treatment initiation were associated with an increased risk of unfavorable outcome.ConclusionsA model of care that included psychosocial support and patient’s enablers led to a high level of treatment success with a very low lost to follow up rate. Limiting the overall treatment success was a high mortality rate which was associated with advanced HIV and a low BMI at presentation. These factors will need to be addressed in order to improve upon the overall treatment success rate in future.