Poor Short-term Outcome Research Articles

Sex‐related difference in outcomes after aortic root replacement

Poorer short-term outcomes have been described for females after cardiovascular surgery. We examined the influence of sex on the outcomes after aortic root replacement (ARR). Medical records of 848 patients (females, n = 159/848, 19%) who underwent ARR at our center from 2005 to 2018 were retrospectively reviewed. Sex differences of the following outcomes were analyzed: the primary end point (in-hospital mortality or stro111ke), secondary end point (new requirement for permanent pacemaker), and long-term survival (median follow-up 21.4 months [interquartile range,1.3-60.0]). Females were significantly older (61.3 vs 58.7 [male]) with higher rates of pre-existing cerebrovascular disease (14% [22/159] vs 7% [52/689]) and previous valve intervention (20% [32/159] vs 13% [89/689]) but less myocardial infarction [1%(1/159) vs 7%(48/689)]. The surgical indication was different (aneurysm 75% [120/159] vs 87% [602/689], dissection 13% [21/159] vs 6% [41/689]; P < .01]). Females had larger average aneurysm size after controlling for body size (P ≤ .001). There was no sex difference in in-hospital mortality (3% [5/159] vs 2% [16/689]) or stroke (4% [7/159] vs 4% [29/689]). Multivariable logistic regression indicated that female sex was not an independent predictor of combined in-hospital stroke or death (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.28-1.25), confirmed by propensity score analysis. There was no difference in long-term survival (5-year survival, 90.96% vs 93.03%; P = .44). Females had higher incidence of permanent pacemaker requirement [11% (18/159) vs 6% (39/689), P = .03] and female sex was an independent predictor of permanent pacemaker requirement (OR, 2.01; 95% CI, 1.085-3.724; P = .03). While female patients have different baseline characteristics and indication for ARR, they are not exposed to an increased risk of in-hospital mortality or stroke. However, females experience increased incidence of permanent pacemaker requirement.

TNFRSF11B polymorphisms predict poor outcome after large artery atherosclerosis stroke.

Osteoprotegerin is involved in the progression of atherosclerosis. This study aimed to determine whether TNFRSF11B polymorphisms are associated with prognosis of large artery atherosclerosis (LAA) stroke. Three TNFRSF11B polymorphisms (rs2073617, rs2073618 and rs3134069) were genotyped in 1010 patients with LAA stroke. Short-term outcome was evaluated using the modified Rankin Scale score at 3-month after stroke onset. Long-term outcome was assessed using the stroke recurrence. We found that rs2073617G was associated with an increased risk of poor outcome of LAA stroke (additive model: odds ratio (OR)=1.35, 95% confidence interval (CI)=1.06-1.73). This association was also observed in rs3134069C (additive model: OR=1.53, 95% CI=1.10-2.12). Furthermore, when we combined these two polymorphisms according to the numbers of risk alleles (rs2073617G and rs3134069C), we found that the patients with 3-4 risk alleles were statistically significantly associated with an increased risk of poor outcome of LAA stroke (OR=1.90, 95% CI=1.10-3.28) compared with 0-2 risk alleles, and this increased risk was more evident among those with hypertension (OR=2.02, 95% CI=1.04-3.91), those without diabetes (OR=2.02, 95% CI=1.02-4.01) and those with smoking (OR=2.43, 95% CI=1.09-5.42). In silico analysis showed that rs2073617 and rs3134069 are located in various histone modification marked regions, DNase I hypersensitive sites and can change the binding of regulatory motifs. Moreover, rs2073617 is also located in the binding site of transcription factors. Our findings suggested that TNFRSF11B polymorphisms may be associated with an increased risk of short-term poor outcome of LAA stroke.

Incidence and Effect of Diabetes Insipidus in the Acute Care of Patients with Severe Traumatic Brain Injury.

Literature on diabetes insipidus (DI) after severe traumatic brain injury (TBI) is scarce. Some studies have reported varying frequencies of DI and have showed its association with increased mortality, suggesting it as a marker of poor outcome. This knowledge gap in the acute care consequences of DI in severe TBI patients led us to conceive this study, aimed at identifying risk factors and quantifying the effect of DI on short-term functional outcomes and mortality. We assembled a historic cohort of adult patients with severe TBI (Glasgow Coma Scale ≤ 8) admitted to the intensive care unit (ICU) of a tertiary-care university hospital over a 6-year period. Basic demographic characteristics, clinical information, imaging findings, and laboratory results were collected. We used logistic regression models to assess potential risk factors for the development of DI, and the association of this condition with death and unfavorable functional outcomes [modified Rankin scale (mRS)] at hospital discharge. A total of 317 patients were included in the study. The frequency of DI was 14.82%, and it presented at a median of 2days (IQR 1-3) after ICU admission. Severity according to the Abbreviated Injury Scale (AIS) score of the head, intracerebral hemorrhage, subdural hematoma, and skull base fracture was suggested as risk factors for DI. Diagnosis of DI was independently associated death (OR 4.34, CI 95% 1.92-10.11, p = 0.0005) and unfavorable outcome (modified Rankin Scale = 4-6) at discharge (OR 7.38; CI 95% 2.15-37.21, p = 0.0047). Diabetes insipidus is a frequent and early complication in patients with severe TBI in the ICU and is strongly associated with increased mortality and poor short-term outcomes. We provide clinically useful risk factors that will help detect DI early to improve prognosis and therapy of patients with severe TBI.

Effects of case volume and comprehensive stroke center capabilities on patient outcomes of clipping and coiling for subarachnoid hemorrhage.

Improved outcomes in patients with subarachnoid hemorrhage (SAH) treated at high-volume centers have been reported. The authors sought to examine whether hospital case volume and comprehensive stroke center (CSC) capabilities affect outcomes in patients treated with clipping or coiling for SAH. The authors conducted a nationwide retrospective cohort study in 27,490 SAH patients who underwent clipping or coiling in 621 institutions between 2010 and 2015 and whose data were collected from the Japanese nationwide J-ASPECT Diagnosis Procedure Combination database. The CSC capabilities of each hospital were assessed by use of a validated scoring system based on answers to a previously reported 25-item questionnaire (CSC score 1-25 points). Hospitals were classified into quartiles based on CSC scores and case volumes of clipping or coiling for SAH. Overall, the absolute risk reductions associated with high versus low case volumes and high versus low CSC scores were relatively small. Nevertheless, in patients who underwent clipping, a high case volume (> 14 cases/yr) was significantly associated with reduced in-hospital mortality (Q1 as control, Q4 OR 0.71, 95% CI 0.55-0.90) but not with short-term poor outcome. In patients who underwent coiling, a high case volume (> 9 cases/yr) was associated with reduced in-hospital mortality (Q4 OR 0.69, 95% CI 0.53-0.90) and short-term poor outcomes (Q3 [> 5 cases/yr] OR 0.75, 95% CI 0.59-0.96 vs Q4 OR 0.65, 95% CI 0.51-0.82). A high CSC score (> 19 points) was significantly associated with reduced in-hospital mortality for clipping (OR 0.68, 95% CI 0.54-0.86) but not coiling treatment. There was no association between CSC capabilities and short-term poor outcomes. The effects of case volume and CSC capabilities on in-hospital mortality and short-term functional outcomes in SAH patients differed between patients undergoing clipping and those undergoing coiling. In the modern endovascular era, better outcomes of clipping may be achieved in facilities with high CSC capabilities.

Effect of nephrology follow-up on long-term outcomes in patients with acute kidney injury: A systematic review and meta-analysis.

Acute kidney injury (AKI) is associated with poor short-term and long-term clinical outcomes. The role of nephrology follow-up in post-AKI management remains uncertain. A systematic review and meta-analysis were performed examining all randomized controlled trials and observational studies assessing the effect of nephrology follow-up on patients' clinical outcomes. The primary outcome was all-cause mortality. The secondary outcomes were renal outcomes, which were defined as a composite of requirement of permanent dialysis and recurrent AKI. Pooled analysis was performed using a random-effect model. We identified six studies (8972 patients, mean follow-up of 49 months). Five were retrospective cohort studies and one was a prospective cohort study. Risk of bias was a concern with all studied. Only four studies reported primary and/or secondary outcomes and were included. Compared with patients without nephrology follow-up, patients with nephrology follow-up had significantly reduced mortality by 22% (three studies, 3240 patients, relative risk [RR] = 0.78, 95% confidence interval [CI] = 0.70-0.88, I2 = 0.0%). Nephrology follow-up did not improve composite renal outcomes with high heterogeneity due to significant differences in reported renal outcomes and follow-up period (two studies, 2537 patients, RR = 1.72, 95% CI = 0.49-6.05, I2 = 90.1%). Current evidence from observational studies is biased. It suggests long-term survival benefits with post-discharge nephrology follow-up in AKI patients. However, due to its low quality, such evidence is only hypothesis-generating. Nonetheless, it provides a rationale for future randomized controlled trials of nephrology follow-up in AKI patients. SUMMARY AT A GLANCE The present meta-analysis assessed the effect of nephrology follow-up on patients' clinical outcomes, and suggested long-term survival benefits in acute kidney injury (AKI) survivors. Although the study inherently comprises potential risks of bias due to paucity of available data, the results provide a rationale for future randomized controlled trials.

Prenatal genetic testing for cystic fibrosis: a systematic review of clinical effectiveness and an ethics review

PurposeWe aimed to assess the clinical value of prenatal testing for cystic fibrosis (CF) and whether ethical considerations would affect endpoint selection. MethodsTo determine effectiveness, we conducted a systematic literature review whose protocol outlined search strategies across eight databases, study inclusion criteria, and prespecified literature screening, data extraction, and synthesis processes. We conducted a scoping search on ethical considerations. ResultsThe genetic test showed good diagnostic performance. A change in clinical management was observed: termination of pregnancy (TOP) occurred in most cases where two pathogenic variants were identified in a fetus of carrier parents (158/167; 94.6%). The TOP rate was lower in pregnancies where CF was diagnosed after fetal echogenic bowel detection (~65%). TOP and caring for a child with CF were both associated with poor short-term parental psychological outcomes. Ethical analyses indicated that informed decisions should have been the main endpoint, rather than CF-affected births prevented. ConclusionCF testing leads to fewer CF-affected births. It is difficult to assess whether this means the test is valuable, since patients may not value TOP primarily in terms of maternal or fetal health outcomes, psychological or otherwise. The value of testing should arguably be measured in terms of improving patient autonomy rather than health.

The ability of an improved qSOFA score to predict acute sepsis severity and prognosis among adult patients.

This study analyzed independent risk factors that could improve the qSOFA scoring system among sepsis patients.This retrospective study evaluated 821 patients (2015–2016) who fulfilled the 2001 International Sepsis Definitions Conference diagnostic criteria. Patients were classified based on their survival outcomes after 28 days, and the predictive values of various predictive scores at admission were compared.The independent risk factors for 28-day mortality were fibrinogen, plasma lactic acid, albumin, oxygenation index, and procalcitonin level >0.5 ng/mL (all P < .05). The “PqSOFA” score combined the qSOFA score with procalcitonin, which provided an area under the curve value of 0.751 (95% CI: 0.712–0.790) for predicting 28-day mortality. A cut-off score of 2 points provided sensitivity of 83.2%, specificity of 54.9%, negative predictive value (NPV) of 33.03%, positive predictive value (PPV) of 92.47%, positive-likelihood ratio (PLR) of 1.85, and negative-likelihood ratio (NLR) of 0.31. The area under the curve for predicting 28-day mortality was significantly greater for the PqSOFA score than for the qSOFA score (Z = 7.019, P < .0001). The PqSOFA score was comparable to the SOFA and APACHE II scores.The PqSOFA score independently predicted poor short-term outcomes among high-risk sepsis patients.

Electromechanical dyssynchrony and short-term outcomes of readmission and death, among heart failure patients in Aminu Kano teaching hospital, Kano State, Nigeria

Background: Cardiac dyssynchrony refers to a difference in the timing of contractions in different chambers and/or segments of the heart. Left ventricular (LV) dyssynchrony is frequently seen in patients with heart failure (HF) and is a poor prognostic marker if left untreated. The impact of cardiac dyssynchrony among HF patients in Nigeria is unknown. We set out to assess the role of electromechanical dyssynchrony in short-term outcomes in terms of readmission and 6-month mortality among HF patients in our hospital. Methods: We conducted a prospective observational study among adult HF patients in our hospital. Electrical and mechanical dyssynchrony were measured using electrocardiography and echocardiography, respectively. Data on the outcome of readmission and death within 6 months were collected. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 16 software. Results: A total of 100 participants were recruited for this study. Electrical dyssynchrony (Duration of QRS complex on ECG > 120ms) was found in 11%, 8 (73%) of them had QRS width between 120 and 150 ms, while in three, the QRS width was >150 ms. The prevalence of interventricular dyssynchrony (LV preejection interval – right ventricular preejection interval ≥40 ms) was found to be 79%, while that of intraventricular (septal to posterior wall motion delay >130 ms) was 75%. Nineteen percent of the study participants were readmitted with worsening HF symptoms, while up to 37% died within the 6 months follow-up period. Electrical dyssynchrony was a significant predictor of short-term readmission and death. There was also a statistically significant difference (P Conclusion: The presence of electromechanical dyssynchrony is associated with a poor short-term outcome of readmission and death. More studies are needed in our country to fully define the burden of dyssynchrony among HF patients in our environment.

Diabetes and Mortality in Acute Coronary Syndrome: Findings from the Gulf COAST Registry.

The prevalence of traditional risk factors such as diabetes mellitus (DM) and obesity are increasing in patients with acute coronary syndrome (ACS). Furthermore, outcomes after ACS are worse in patients with DM. The high prevalence of DM and an early age at onset of ACS have been described in prior publications from the Gulf Coast Database. We aimed to define the effect of DM on total mortality following ACS presentation at 30-days and 1 year based on the Gulf COAST registry database. The Gulf COAST registry is a prospective, multinational, longitudinal, observational cohort study conducted among Gulf citizens admitted with a diagnosis of ACS. The outcomes among patients with DM following ACS were stratified into 2 groups based on their DM status. Cumulative survival stratified by groups and subgroup categories was assessed by the Kaplan-Meier method. Of 3,576 ACS patients, 2,730 (76.3%) presented with non ST-segment elevation myocardial infarction (NSTEMI) and 846 (23.6%) with STEMI. Overall, 1906 patients (53.3%) had DM. A significantly higher in-hospital (4.8%), 30-day (6.7%) and 1-year (13.7%) mortality were observed in patients with DM compared with those without DM. The Kaplan-Meier survival curve showed significant differences in survival of ACS patients with or without DM, with a short period of time-to-event for DM patients with STEMI (30-days) and the longest (1-year) for NSTEMI patients without DM. DM patients presenting with ACS-STEMI have poor short-term outcomes while DMNSTEMI patients have poor long-term outcomes. This highlights the need for strategies to evaluate DM control and integration of care to control vascular risk among this high-risk population.

Evaluation of Serum Ferritin as a Prognostic Marker in Acute Hemorrhagic Stroke.

Background Acute hemorrhagic stroke (AHS) resulting from intracerebral hemorrhage (ICH) is a rampant neurological disorder with devastating consequences, particularly in Indians. Recently, serum ferritin levels have been related to adverse cardiovascular and stroke outcomes. We aimed to evaluate the prognostic utility of serum ferritin in AHS. Materials and Methods Admission serum ferritin levels were estimated in 50 AHS patients with primary supratentorial hemorrhage. Study subjects were categorized based on their prognostic scores in modified Rankin scale (mRS) assessment. Ferritin levels were compared across the study groups, correlated with mRS and other ICH severity indicators. Results Serum ferritin and other ICH severity indices such as Glasgow coma scale (GCS) and ICH volume were significantly altered in the mRS groups by the end of 7th and 30th days of hospitalization. Elevated ferritin levels, ICH volume together with decreased GCS, characterized the groups with adverse prognosis. Serum ferritin moderately correlated with GCS ( r = –0.643), ICH volume ( r = 0.562), and had significantly higher correlations with long-term prognostic scores of 7th day mRS ( r = 0.802) and 30th day mRS ( r = 0.916). Conclusion Elevated admission serum ferritin levels indicate poor AHS short-term and long-term outcomes, thereby making serum ferritin a possible prognostic index for the same.

Leukocyte Count and Adverse Clinical Outcomes in Acute Ischemic Stroke Patients.

Background: Post-ischemic inflammatory response might be affected by many factors. We chose leukocyte count as a marker of inflammatory response and investigated whether the effects of leukocyte count on the clinical outcomes in acute ischemic stroke patients are different according to different factors.Methods: We derived data from the China National Stroke Registry II. Patients with ischemic stroke were classified into four groups by leukocyte count quartiles within the first 24 h after admission. Adverse clinical outcomes were defined as recurrent stroke, all-cause death, and poor functional outcomes (3 ≤ mRS ≤ 5) at 3-months and 1-year follow-up. The subgroup factors were age, sex, history of hypertension, history of diabetes, history of previous stroke, or transient ischemic attack and smoking status. We assessed the association between leukocyte count and adverse clinical outcomes and evaluated this association in different subgroups.Results: A total of 14,678 patients were included. Patients in higher quartiles were likely to be younger, male, smokers, and drinkers, and to have a shorter time from symptom onset to arrival, a more proportion of history of diabetes, atrial fibrillation, and hypertension, and a higher severity of stroke. Higher quartiles were associated with elevated risk of adverse clinical outcomes at 3-months and 1-year follow-up. Leukocyte count had a moderate accuracy to predict clinical outcomes. There was no difference in the relationship between leukocyte count and adverse clinical outcomes across subgroups such as age, sex, history of hypertension, and smoking. The effect of leukocyte count on all-cause death was pronounced among patients with previous stroke or transient ischemic attack, and the effect of leukocyte count on short-term poor functional outcomes was also pronounced among patients without diabetes.Conclusions: Leukocyte count is associated with short-term and long-term clinical outcomes of acute ischemic stroke and may have predictive value, especially in patients with certain specific characteristics.

Contrast Extravasation is Predictive of Poor Clinical Outcomes in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke in the Anterior Circulation

ObjectiveTo investigate whether contrast extravasation on dual-energy computed tomography (DECT) in patients with acute ischemic stroke (AIS) after endovascular therapy (EVT) are related to hemorrhagic transformation (HT) and poor short-term clinical outcomes. MethodsA retrospective analysis was conducted on AIS patients who underwent EVT at Xuanwu hospital between November 2016 and January 2019. DECT was performed on all patients within 24 hours after EVT. Baseline demographic and clinical data were analyzed between patients with and without contrast extravasation and between patients with HT and non-HT, good and poor outcomes at 3 months post-EVT. ResultsA total of 166 patients were included in the study with 51 (30.7%) patients experiencing contrast extravasation. Compared to patients without contrast extravasation, patients with contrast extravasation had longer onset to reperfusion time (444.8 minutes versus 374.0 minutes, P = .044) and higher percentages of greater than 3 retriever passes (16.7% versus 31.4%, P = .030). Contrast extravasation was associated with higher risk of HT (P = .038), poor outcome after discharge (P = .030), and longer hospital stay (P = .034). Multivariate analysis showed that contrast extravasation occurrence was an independent factor for HT (OR = 2.150, 95% CI 1.060-4.360, P = .034) and poor short-term outcome (OR = 2.936; 95% CI 1.147-7.518, P = .025). ConclusionsThe presence of contrast extravasation within 24 hours of EVT may be associated with higher risks of HT and may be predictive of unfavorable functional outcomes in AIS patients.

TAVI chez les femmes, des résultats très encourageants

The population of elderly patients comprises a high percentage of women. This population is more vulnerable due to the presence of numerous comorbidities and is, therefore, particularly exposed to the risk of aortic valve degeneration, resulting in aortic valve stenosis whose symptoms are predictors of poor short-term outcomes. In the presence of symptomatic aortic stenosis, the recommended therapeutic option in this vulnerable population is the implementation of transcatheter aortic valve implantation, preferably via the femoral route. The outcomes of this procedure are better in women than in men despite a more frequent occurrence of vascular, bleeding and cerebral complications. Several hypotheses have been reported in the literature regarding the reasons for such differences. Among other reasons, it is likely that in female patients, the myocardium adjusts better to the occurrence of aortic stenosis and that recovery after valve treatment is also more optimal. Another explanation is the higher frequency of coronary artery disease in this older population. This has a considerable impact on the outcome even when coronary lesions are treated prior to valve implantation. There is still room for improvement and progress can be achieved by further reducing the size of the equipment used in order to decrease the diameter of the vascular access, and by continuing to simplify TAVI procedures. Less invasive techniques should result in decreased complication rates. In addition, dedicated studies should allow us to further improve our practice in this growing population of vulnerable patients.

Association of medication non-adherence with short-term allograft loss after the treatment of severe acute kidney transplant rejection

BackgroundMedication non-adherence is a risk factor for acute kidney transplant rejection. The association of non-adherence with short-term allograft loss in patients who develop acute rejection and are subsequently treated with maximal therapy is unknown.MethodsWe conducted a retrospective single center cohort study of adult patients who developed acute rejection from January 2003 to December 2017 and were treated with lymphocyte depletion. Clinicopathologic characteristics including adherence status were collected and descriptive statistics utilized to compare groups. The primary outcome was all-cause graft loss at 6 months after acute rejection treatment. A multivariable logistic regression quantified the association of non-adherence with the outcome.ResultsA total of 182 patients were included in the cohort, of whom 71 (39%) were non-adherent. Compared to adherent patients, non-adherent patients were younger (mean age 37y vs 42y), more likely to be female (51% vs 35%) and developed acute rejection later (median 2.3y vs 0.5y from transplant). There were no differences in estimated glomerular filtration rate or need for dialysis on presentation, Banff grade, or presence of antibody mediated rejection between the 2 groups. Overall, 48 (26%) patients lost their grafts at 6 months after acute rejection treatment. In adjusted analysis, non-adherence was associated with all-cause graft loss at 6 months after acute rejection treatment [OR 2.64 (95% CI 1.23–5.65, p = 0.012].ConclusionsAfter adjusting for common confounders, non-adherent patients were at increased risk for short-term allograft loss after a severe acute rejection despite lymphocyte depletion. This finding may aid clinicians in risk stratifying patients for poor short-term outcomes and treatment futility.

Cardio embolic stroke and blood biomarkers: diagnosis and predictors of short-term outcome

BackgroundThe brain is a productive source of a variety of enzymes and any brain injury like a stroke to brain tissue could similarly result in an increase in these enzymes in cerebrospinal fluid and serum. Evaluation of these enzymes represents a simple method for the ischemic stroke subtype diagnosis and prognosis. Objective: This study aimed to determine the role of brain natriuretic peptide (BNP), d-dimer, creatine–kinase-MB (CK-MB), C-reactive protein (CRP) serum levels, and globulin/albumin ratio in the diagnosis of CES stroke and its ability to predict short-term outcome.MethodsThis study was conducted on 96 patients with acute ischemic stroke, subdivided into two groups: group Ι was 48 patients with cardio-embolic stroke and group ΙΙ was 48 patients with non-cardio-embolic. All patients were subjected to the assessment of serum BNP, d-dimer and CK-MB, and CRP and globulin/albumin ratio within the first 24 h of stroke. In the third week, they were assessed by mRS.ResultsThe mean levels of BNP, d-dimer level, and CK-MB were significantly higher in patients with cardio-embolic stroke than in patients with non-cardio-embolic stroke (P < 0.001) and also were associated with poor short-term outcome.ConclusionElevated plasma levels of BNP, d-dimer levels, and CK-MB can be used as surrogate biomarkers for the diagnosis of cardio-embolic stroke and prediction of poor short-term outcomes.

In-Hospital Post-Operative Infection after Heart Transplantation: Epidemiology, Clinical Management, and Outcome.

Background: Infection is a major cause of morbidity and mortality after heart transplantation (HT). Little information about its importance in the immediate post-operative period is available. The aim of this study was to analyze the characteristics, incidence, and outcomes of in-hospital post-operative infections after HT. Methods: We conducted an observational, single-center study based on 677 adults who underwent HT from 1991 to 2015 and who survived the surgical intervention. In-hospital post-operative infections were identified retrospectively according to the medical finding in the clinical records. Results: Over a mean hospital stay of 24.5 days, 239 patients (35.3%) developed 348 episodes of infection (2 episodes per 100 patient-days). The most common sources of infection were those related to invasive procedures (respiratory infections, 115 [33%]; urinary tract infections, 47 [13.5%]; bacteremia, 42 [12.1%]; surgical site infections, 25 [7.2%]), in addition to abdominal focus (33, 9.5%). Enterobacteriaceae (76, 21.8%) and gram-positive cocci (58, 16.7%) were the predominant germs, although opportunistic infections were not infrequent (69, 19.8%). Ninety-five septic episodes were detected with a mean Sequential Organ Failure Assessment Score of 9.5 ± 5.3 points, with hemodynamic failure being the most severe organ dysfunction and renal dysfunction the most frequent one. Management included broad-spectrum antibiotics in 48.8% of episodes and surgical management in 13.8%. The overall antimicrobial success rate was 96.3%. Higher in-hospital mortality was observed among infected patients (15.1% vs. 10.3%), but this difference was not statistically significant (p = 0.067). The one-year survival and events were not different between patients suffering from a post-operative infection and those who did not. Conclusions: In-hospital infections were frequent in the post-operative period after HT and were associated with a poor short-term outcome. Patients who survived sepsis had a similar one-year morbidity and mortality compared with patients who did not develop an infection.

8.7 CHILD AND ADOLESCENT PSYCHIATRY AS PARTNERS AND LEADERS IN CHILD WELFARE SYSTEMS

Child and adolescent psychiatrists are critical partners supporting child welfare goals of permanency, safety, and well-being. However, they do so in the context of many challenges, including the emotional and behavioral sequelae of maltreatment, complex family structures, and multiple systems of care. Failure to provide leadership within and across these systems risks the following: poor short-term outcomes; reduced permanency, safety and well-being; and long-term limits to functional capacity. This presentation aims to provide information about child welfare and partner systems that will strengthen the capacity of child and adolescent psychiatrists to provide comprehensive clinical care, address challenges facing children and families, and advocate for system changes that support positive outcomes.

Gastric endoscopic submucosal dissection: a systematic review and meta-analysis on risk factors for poor short-term outcomes.

Endoscopic submucosal dissection (ESD) is now established as the first option to manage early gastric neoplasms, but its efficacy may vary according to diverse factors. We aimed to systematically identify risk factors for poor short-term outcomes of gastric ESD with the purpose to improve patients' selection and management. Three online databases (MEDLINE, ISI Web of Knowledge and Scopus) were searched (last search on June 2018) for poor outcomes of gastric ESD (deep submucosal invasion, piecemeal/incomplete resection, noncurative resection and local recurrence). One hundred five studies were included referring to 52.126 ESDs. Undifferentiated histology and upper location (vs lower) were associated with submucosal invasion [odds ratio (OR) = 2.42 [95% confidence interval (CI), 1.62-3.61] and OR = 3.20 (1.04-9.86), respectively] and deep submucosal invasion [OR = 2.98 (2.02-4.39) and OR = 2.35 (1.45-3.81), respectively]. Lesion size greater than 30 mm and ulceration were associated with piecemeal resection [OR = 2.78 (1.17-6.60) and OR = 2.76 (1.23, 6.20), respectively]. Lesion size greater than 30 mm, ulceration, upper location and fibrosis were risk factors for incomplete resection [OR = 3.83 (2.68-5.49), OR = 4.06 (1.62-10.16), OR = 3.71 (2.49-5.54) and OR = 4.46 (1.66-11.96), respectively]. A noncurative resection was more often observed for lesions located in the upper third of the stomach [OR = 1.49 (1.24-1.79)], depressed morphology [OR = 1.49 (1.04-2.12)] and those outside standard criteria [OR = 3.56 (2.31-5.48)]. Older age was significantly linked with local recurrence rates [OR = 3.08 (1.13-5.02)]. Several risk factors influence poor efficacy short-term outcomes of gastric ESD that may be used to inform both patients and health providers about the expected efficacy.

Chagas disease is associated with a worse prognosis at 1-year follow-up after implantable cardioverter-defibrillator for secondary prevention in heart failure patients.

There are conflicting data regarding the efficacy of implantable cardioverter-defibrillator (ICD) in Chagas disease (CD) patients. This study aims to evaluate the short-term outcome after ICD for secondary prevention, in a population where CD is a prevalent cause of heart failure (HF). Consecutive patients with HF and reduced left ventricular ejection fraction (LVEF), who underwent ICD implantation for secondary prevention of SCD. Clinical and demographic data were collected to investigate mortality predictors at 1 year. During the study period, 117 patients underwent ICD implantation, of which 108 were included. The most frequent causes of HF was CD: 52 (48.1%) and ischemic cardiomyopathy: 20 (18.5%). Chagas and non-Chagas patients were well balanced-male: 32 (61.5%) vs 38 (67.9%), P = .548; age: 59.2 (±10.9) vs 56.8 (±13.4), P = .681; and LVEF: 34.1 (±0.2) vs 31.3 (±8.7), P = .064, respectively. At the mean follow-up of 15.7 months, overall mortality occurred in 14 (12.9%) patients, with a higher incidence in patients with CD cardiomyopathy, 11 (21.2%) vs 3 (5.4%), P = .021 (log-rank). In the multivariate analysis, CD remained as an independent predictor for death (hazard ratio: 4.62, confidence interval [95% CI]: 1.27-16.81, P = .021). CD was associated with a poor short-term outcome in patients with HF submitted to ICD implantation for secondary prevention when compared with other HF etiologies. In this specific HF population, ICD indication should be individualized, considering the worst prognosis of these patients.

The relationship between the time of cerebral desaturation episodes and outcome in aneurysmal subarachnoid haemorrhage: a preliminary study

In this preliminary study we investigated the relationship between the time of cerebral desaturation episodes (CDEs), the severity of the haemorrhage, and the short-term outcome in patients with aneurysmal subarachnoid haemorrhage (aSAH). Thirty eight patents diagnosed with aneurysmal subarachnoid haemorrhage were analysed in this study. Regional cerebral oxygenation (rSO2) was assessed using near infrared spectroscopy (NIRS). A CDE was defined as rSO2 < 60% with a duration of at least 30 min. The severity of the aSAH was assessed using the Hunt and Hess scale and the short-term outcome was evaluated utilizing the Glasgow Outcome Scale. CDEs were found in 44% of the group. The total time of the CDEs and the time of the longest CDE on the contralateral side were longer in patients with severe versus moderate aSAH [h:min]: 8:15 (6:26–8:55) versus 1:24 (1:18–4:18), p = 0.038 and 2:05 (2:00–5:19) versus 0:48 (0:44–2:12), p = 0.038. The time of the longest CDE on the ipsilateral side was longer in patients with poor versus good short–term outcome [h:min]: 5:43 (3:05–9:36) versus 1:47 (0:42–2:10), p = 0.018. The logistic regression model for poor short-term outcome included median ABP, the extent of the haemorrhage in the Fisher scale and the time of the longest CDE. We have demonstrated that the time of a CDE is associated with the severity of haemorrhage and short-term outcome in aSAH patients. A NIRS measurement may provide valuable predictive information and could be considered as additional method of neuromonitoring of patients with aSAH.