Significant Determinant Of Outcome Research Articles

Outcomes and Disease Spectrum of LBW Neonates in a Secondary Health Facility.

Globally, 30 million low birth weight (LBW) babies are born every year and 95% of them are from developing countries. LBW neonates are at a high risk of mortality, morbidity, and long-term disability. The objective of this study is to investigate outcomes and disease spectrum among low birth weight neonates. This is a prospective, observational study conducted on 540 neonates admitted in the Mother and Child Hospital, Akure, Ondo State, Nigeria, from 2017 to 2018. Questionnaire, interview, clinical, and diagnostic procedures were used as research tools. There were 137 low birth weight (LBW) neonates, with the mean mothers' age of 31.92 ± 6.60. Of the 540 neonates, 69 (50.4%) and 68 (49.6%) were term and preterm, respectively. There were 64 female neonates (46.7%) and 73 male neonates (53.3%). The mean weight of the neonates was 1.82 ± 0.44 kg, and mean number of days on admission was 6.42 ± 6.75 days. Neonatal sepsis (NNS) was the highest morbidity 51 (37.2%) among the LBW neonates, followed by prematurity 47 (34.4%) and neonatal jaundice (NNJ) 18 (13.1%). Sex (χ2 = 3.584, p=0.310), mode of delivery (χ2 = 4.669, p=0.198), and gestational age (χ2 = 3.904, p=0.272) were not a significant determinant of outcome among LBW neonates. Men were 2.36 times more likely to be preterm (OR = 2.36, 95% CL = 1.01–5.54, p=0.048) among LBW neonates. Outcomes of LBW neonates who were delivered by SVD were not significant compared to preterm delivered by CS (OR = 0.46, 95% CL = 0.13–1.65, p=0.096). Sixty percent (60%) of the mothers had Prolonged Rupture of Membranes (PROM). Morbidities such as hypothermia (72.2%), apnoea (63.6%), haemorrhagic disease of the newborn (HDN) (66.7%), and respiratory distress syndrome (RDS) (66.7%) were more observed with preterm LBW neonates. Importance of qualitative antenatal care (ANC) should be emphasized; anticipation and prevention of LBW births can help mitigate some of the problems they are prone to.

216. Bacterial Genotype and Clinical Outcomes in Solid Organ Transplant Recipients with Staphylococcus aureus Bacteremia

BackgroundSolid organ transplant (SOT) recipients are characterized by extensive healthcare exposure and have high rates of Staphylococcus aureus bacteremia (SAB). The clinical characteristics and outcome determinants of SAB in this population are poorly understood. We undertook a prospective cohort study compared the bacterial genotype and clinical outcomes of SAB among SOT and non-solid organ transplant (non-SOT) recipients. MethodsConsecutive patients presenting to our institution with SAB between January 1, 2016 and December 31, 2019 were eligible for study inclusion. Each subject’s initial S. aureus bloodstream isolate was genotyped using spa typing and assigned to clonal complexes using Ridom StaphType software. ResultsA total of 32 SOT and 634 non-SOT recipients with SAB were included. Bacterial genotype did not differ significantly between SOT and non-SOT recipients (p=0.4855), including the proportion of SAB caused by USA300 (12.5% vs 16.7%, p=0.6339). Ninety-day mortality and incidence of metastatic complications did not significantly differ between SOT and non-SOT recipients (18.8% vs 30.1%, p=0.2329, and 37.5% vs 48.6%, p=0.2769, respectively). Transplant status was significantly associated with septic shock (50.0% vs 21.8%, adjusted OR 2.63, 95% CI: 1.22 to 5.66). Infection with USA300 was not associated with 90-day mortality or septic shock among SOT recipients (p=1.0000 for both). Staphylococcus aureus Genotype by Transplant Status ConclusionIn conclusion, SOT recipients with SAB do not experience greater mortality than non-SOT recipients. Differences in genotype of the infecting bacteria do not appear to be a significant determinant of outcome in SOT recipients with SAB. Disclosures Vance G. Fowler, Jr., MD, MHS, Achaogen (Consultant)Advanced Liquid Logics (Grant/Research Support)Affinergy (Consultant, Grant/Research Support)Affinium (Consultant)Akagera (Consultant)Allergan (Grant/Research Support)Amphliphi Biosciences (Consultant)Aridis (Consultant)Armata (Consultant)Basilea (Consultant, Grant/Research Support)Bayer (Consultant)C3J (Consultant)Cerexa (Consultant, Other Financial or Material Support, Educational fees)Contrafect (Consultant, Grant/Research Support)Debiopharm (Consultant, Other Financial or Material Support, Educational fees)Destiny (Consultant)Durata (Consultant, Other Financial or Material Support, educational fees)Genentech (Consultant, Grant/Research Support)Green Cross (Other Financial or Material Support, Educational fees)Integrated Biotherapeutics (Consultant)Janssen (Consultant, Grant/Research Support)Karius (Grant/Research Support)Locus (Grant/Research Support)Medical Biosurfaces (Grant/Research Support)Medicines Co. (Consultant)MedImmune (Consultant, Grant/Research Support)Merck (Grant/Research Support)NIH (Grant/Research Support)Novadigm (Consultant)Novartis (Consultant, Grant/Research Support)Pfizer (Grant/Research Support)Regeneron (Consultant, Grant/Research Support)sepsis diagnostics (Other Financial or Material Support, Pending patent for host gene expression signature diagnostic for sepsis.)Tetraphase (Consultant)Theravance (Consultant, Grant/Research Support, Other Financial or Material Support, Educational fees)Trius (Consultant)UpToDate (Other Financial or Material Support, Royalties)Valanbio (Consultant, Other Financial or Material Support, Stock options)xBiotech (Consultant)

Clinicopathological and molecular characteristics of early-onset stage III colon adenocarcinoma: An analysis of 25 studies with 35,713 patients in the Adjuvant Colon Cancer End Points (ACCENT) database.

3597 Background: Colon cancer (CC) incidence and mortality have decreased since the 1970s, but the incidence in young adults (20-49 years) is increasing. There are limited data suggesting that, as a group, patients with early onset CRC (eoCC) may have different phenotypic characteristics compared to those with late onset CRC (loCC, age ≥ 50 years). Methods: Individual patient data on 35,713 subjects with stage III CC from 25 randomized studies (recruiting between 1987 and 2009) in the ACCENT database were pooled. The distributions of demographics, clinicopathological features, biomarkers, and outcome data were summarized by age group. Overall survival (OS), disease-free survival (DFS), recurrence free rate (RFR), and survival after recurrence (SAR) were assessed by Kaplan-Meier curves and Cox models stratified by treatment arms within studies, adjusting for gender, race, body mass index, performance status, disease stage, grade, risk group, number of lymph nodes examined, disease sidedness and molecular markers. Results: Using a 5% difference between age groups as the clinically meaningful cutoff, patients with stage III eoCC (n = 6246) had similar distributions according to gender, race, PS, risk group, tumor sidedness and T/N stage compared to those with loCC (n = 29467). Patients with eoCC were significantly less likely to be overweight (30.2% vs 36.2%) but more commonly had ≥ 12 lymph nodes resected (69.5% vs 58.7%). The eoCC tumors were more frequently mismatch repair deficient (16.4% vs 11.5%), and less likely to have BRAFV600E (5.6% vs 14.0%), suggesting a higher frequency of Lynch syndrome in eoCC. In univariate analysis, patients with stage III eoCC had significantly better OS, DFS, and SAR; the difference between 3-year DFS and RFR strongly suggests the OS/DFS difference between these the eoCC and loCC may be due to increased competing risks and comorbidities in patients with loCC. In multivariate analysis, age at onset lost its prognostic value when outcome was adjusted for molecular markers. The clear relation between age of onset and KRAS/BRAF status was confirmed in the interaction analysis. Conclusions: Tumor biology was an important determinant of prognosis regardless of patient age. In multivariate analysis age of onset was not a statistically significant determinant of outcome.[Table: see text]

Sex-specific impact of patterns of imageable tumor growth on survival of primary glioblastoma patients

BackgroundSex is recognized as a significant determinant of outcome among glioblastoma patients, but the relative prognostic importance of glioblastoma features has not been thoroughly explored for sex differences.MethodsCombining multi-modal MR images, biomathematical models, and patient clinical information, this investigation assesses which pretreatment variables have a sex-specific impact on the survival of glioblastoma patients (299 males and 195 females).ResultsAmong males, tumor (T1Gd) radius was a predictor of overall survival (HR = 1.027, p = 0.044). Among females, higher tumor cell net invasion rate was a significant detriment to overall survival (HR = 1.011, p < 0.001). Female extreme survivors had significantly smaller tumors (T1Gd) (p = 0.010 t-test), but tumor size was not correlated with female overall survival (p = 0.955 CPH). Both male and female extreme survivors had significantly lower tumor cell net proliferation rates than other patients (M p = 0.004, F p = 0.001, t-test).ConclusionDespite similar distributions of the MR imaging parameters between males and females, there was a sex-specific difference in how these parameters related to outcomes.

Dengue hepatitis with acute liver failure: Clinical, biochemical, histopathological characteristics and predictors of outcome.

Hepatitis infection from non-hepatotropic viruses such as dengue virus (DENV) is increasing worldwide. There is increasing recognition of the changing epidemiology and atypical presentations of DENV infection including acute liver failure (ALF). There is paucity of data regarding incidence, disease characteristics, and markers of prognosis in patients who develop DENV-related ALF. We aimed to study the incidence, clinical features, laboratory characteristics, and determinants of outcome in patients of DENV presenting with ALF. We reviewed all patients with DENV infection and focused on DENV-related ALF from 2014 to 2017. Diagnosis of DENV and ALF was confirmed by serological tests and standard criteria, respectively. Thirty-six patients (20 men, mean age 32.3) developed ALF among 10108 patients with DENV infection (0.35%). Twenty-one patients died (58.3%). Although bilirubin, aspartate and alanine aminotransferase, and international normalized ratio were markedly elevated in all patients with DENV ALF, there was no statistically significant difference between survivors and non-survivors. Lactate levels, pH at admission, and model for end-stage liver disease (MELD) score were the only predictors of mortality. Lactate levels were significantly higher in non-survivors (11.5±4.2mmol/L) than survivors (6.3±3.6mmol/L) (P<0.001). MELD score in non-survivors (26.7±10.2) was significantly higher than in survivors (20±7.2) (P=0.039). Receiver operator characteristic curve showed lactate or pH to be a superior prognostic marker than MELD with an area under the curve of 0.80, 0.79, and 0.70, respectively. Dengue hepatitis progressed to ALF in 0.35%. Development of ALF was associated with a high mortality (>50%). Lactate level, pH, and MELD score at admission were significant determinants of outcome.

Ketogenic Diet: from the Historical Records to Use in Elite Athletes.

To review the available literature/evidence on low carbohydrate/high fat (LCHF) and low carbohydrate ketogenic (LCKD) diets' effects on human athletic performance and to provide a brief review of the physiology and history of energy systems of exercise. Multiple studies have been conducted in an attempt to answer this question, many within the last 3-5 years. Studies are heterogenous in design, intervention, and outcome measures. Current available data show that LCHF and LCKD do not significantly enhance or impair performance in endurance or strength activities. However, there is a trend towards improved body composition (greater percent lean body mass) across multiple studies. While this may not translate to enhanced performance in the primarily laboratory conditions in the reviewed studies, there could be a benefit in sports in which an athlete's strength-to-weight ratio is a significant determinant of outcome.

SAT-040 HAEMODIAFILTRATION IMPROVES THE CARDIOVASCULAR RISK PROFILE AND PATIENT RELATED OUTCOME MEASURES COMPARED TO CONVENTIONAL HAEMODIALYSIS IN CHILDREN – THE HDF, HEART AND HEIGHT (3H) STUDY

Fluid overload, hypertension and cardiovascular disease are common in children on dialysis. In adults, haemodiafiltration (HDF) is shown to reduce cardiovascular mortality compared to conventional haemodialysis (HD), but causes for this are not clear and data in children are scarce. We performed a non-randomized parallel-arm clinical trial within the International Paediatric Haemodialysis Network registry to compare outcomes on HD versus post-dilution on-line HDF: the HDF, Heart and Height (3H) study. Co-primary outcome measures were annualised changes in carotid intima-media thickness standard deviation score (cIMT-SDS) and height-SDS. ClinicalTrials.gov: NCT02063776 190 children (from 28 centres in 10 countries across Europe and North America) were recruited, and 177 fulfilled inclusion criteria. 133 children (78 on HD and 55 on HDF) completed one-year follow-up. There was no difference between HD and HDF groups in age, gender, underlying renal disease, comorbidities, dialysis vintage, access type, blood flow or presence of residual renal function. There were 44 dropouts, mainly (79%) due to transplantation; there were no deaths. The median convective volume achieved in the HDF group was 13.33 (inter-quartile range 12.4 to 14.5) ml/m2/session. Annualised change in cIMT SDS was 10-fold lower in HDF compared to HD (0.013 vs 0.48; p=0.002; Figure 1). On propensity score analysis, after adjusting for potential confounders, children on HD had a +0.47 greater increase in annualised cIMT-SDS (95%CI 0.07-0.87; p=0.02) compared to those on HDF. The 24-hour mean arterial pressure (MAP)-SDS increased on HD but reduced on HDF. Serum β2-microglobulin, PTH and high-sensitivity CRP were lower and haemoglobin was higher in HDF patients at 1-year. Predictors of higher cIMT-SDS and MAP-SDS at 12-months (data adjusted for country and baseline values) were HD group, higher inter-dialytic weight gain and ultrafiltration rate and higher β2-microglobulin. Height-SDS increased in HDF but remained static in HD. Importantly, the type of vascular access, blood flow rate and residual renal function did not correlate with cIMT SDS, suggesting that convective clearance is a significant determinant of outcome. Patient related outcome measures that are primarily associated with fluid status, such as the post-dialysis recovery time, headaches, dizziness and cramps, were less frequent and less severe in HDF compared to HD patients. Lower inter-dialytic weight gain on HDF, implying lower ultrafiltration rates per session and greater hemodynamic stability, was strongly associated with fewer symptoms. HDF patients had improved school attendance and greater physical activity scores, but there was no difference in hospitalisation rates. A significant limitation of the study is that randomization was not possible due to small patient numbers. In conclusion, 3H, the largest paediatric dialysis study to date, has shown that HDF improves blood pressure and hemodynamic stability and increases the removal of middle-molecular weight uremic toxins that may, in turn, may halt the progression of vascular disease, improve growth rates and patient related outcome measures compared to conventional HD. Randomised trials to study to confirm these outcomes are required.

Standardized Approach to Intervention for Intestinal Malrotation in Single Ventricle Patients with Heterotaxy Syndrome: Impact on Interstage Attrition and Time to Superior Cavopulmonary Connection.

Heterotaxy syndrome (HS) is a significant determinant of outcome in single ventricle (SV) physiology. Attrition rate and time-related events associated with intestinal malrotation (IM) are, yet, to be determined. We sought to evaluate hospital and interstage outcomes in relation with operative intervention for IM (IMO). Twelve SV/HS patients, who underwent IMO, from January 2004 to December 2016, were studied. Early shunt failure, time to superior cavopulmonary connection (SCPC) and interstage attrition were assessed. Since September 2014, based on a comprehensive standardized protocol, IMO was performed at the time of hospitalization for stage-I palliation (S1P) irrespective of clinical manifestations. Patients were assigned to Group A (n = 8): expectant /symptoms-driven versus Group B (n = 4): protocol-driven. At S1P 7 had systemic-to-pulmonary shunt (SPS), 1 SPS with anomalous pulmonary venous return (APVR) repair (Group A) compared to 2 SPS, 1 SPS with APVR repair and 1 Norwood operation (Group B). Median duration from S1P to IMO was 82days (range 57-336; Group A) compared to 14days (range 11-31; Group B); p < 0.05. Median age at IMO was 87days (range 8-345) [Group A: 99days (range 68-345) vs Group B: 25days (range 8-39)] (p < 0.05). Early SPS failure occurred in 25% (2 of 8) for Group A compared to none in Group B (p < 0.05). Hospital mortality following IMO was 25% [Group A: 37.5% (3 of 8) vs Group B: 0; p < 0.05]. Interstage survival was 67% [Group A: 50% (4 of 8) vs Group B: 100%; p < 0.05]. Time to SCPC following S1P was 186days (range 169-218) for Group A compared to 118days (range 97-161) (Group B); p < 0.05. Operative intervention for IM in SV/HS is associated with significant interstage attrition and might impact the time to SCPC. SPS is at risk for early failure after IMO. A comprehensive standardized concept can mitigate detrimental implications.

Impact of Sex on Ventricular-Vascular Stiffness and Long-Term Outcomes in Heart Failure With Preserved Ejection Fraction: TOPCAT Trial Substudy.

BackgroundWomen have higher vascular stiffness with aging. The aim of this study was to characterize sex differences in vascular and ventricular structure and function, and to investigate the impact on the primary outcome in the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial).Methods and ResultsData from the Americas cohort of the TOPCAT trial were analyzed. Patients with echocardiography (n=654) were compared according to sex, and achievement of the primary end point (a composite of death from cardiovascular causes and heart failure hospitalization) assessed. Echocardiography revealed higher arterial, systolic, and diastolic ventricular elastance and worse ventricular‐vascular coupling in women. Women had better overall survival and heart failure hospitalization outcomes (hazard ratio 0.74, 95% CI 0.57–0.98, P=0.034), however, determinants of achievement of the primary outcome differed between the sexes. Pulse pressure was a key determinant of outcome in women (hazard ratio 1.04, 95% CI 1–1.09, P=0.034) whereas in men heart rate (hazard ratio 1.61, 95% CI 1.02–2.52 per 10 mm Hg increase, P=0.04) and B‐type natriuretic peptide (hazard ratio 1.01, 95% CI 1–1.02 per 10 ng/mL increase P=0.02) were associated with poorer outcome.ConclusionsOutcomes in patients with heart failure with preserved ejection fraction appear to be differentially influenced by key physiological factors that vary according to sex. In women, ventricular‐vascular stiffening was the most significant determinant of outcome, whereas in men overall survival was influenced by heart rate and B‐type natriuretic peptide; this highlights key sex differences in the pathophysiology and outcomes of heart failure with preserved ejection fraction and warrants further exploration.Clinical Trial RegistrationURL: https://clinicaltrials.gov. Unique identifier: NCT00094302.

Can post-hoc video review of robotic pancreaticoduodenectomy predict portal/superior mesenteric vein margin status in pancreatic adenocarcinoma?

BackgroundAchieving margin negative resection is a significant determinant of outcome in pancreatic adenocarcinoma (PDA). However, because of the fibrotic nature of PDA, it can be difficult to discriminate fibrosis from active disease intra-operatively. We sought to determine if post-hoc video review of robotic pancreatico-duodenectomy (RPD) could predict the portal/superior mesenteric vein (PV/SMV) margin status on final pathology. MethodsExperienced pancreatic surgeons, blinded to patient and operative variables, reviewed the PV/SMV margin for available RPD videos of consecutive PDA patients from 9/2012 through 6/2017. Results107 RPD videos were reviewed. Of 76 patients (71%) predicted to have a negative vein margin on video review, 20 patients (26%) had a pathologic positive margin. 25 of 31 patients (81%) predicted to have positive margin on video review were positive on pathology. The specificity of video prediction was 90.3% with a sensitivity of 55.6% and an accuracy of 75.7%. ConclusionPost-hoc video review prediction is unable to reliably predict a positive (R1) margin at the portal vein/SMV, suggesting that intra-operative clinical assessment may be suboptimal in determining the need for more extensive resections.

Donor Age Determines Outcome in Acute Leukemia Patients Undergoing Haploidentical Hematopoietic Cell Transplantation

▪IntroductionHaploidentical hematopoietic cell transplantation (haplo-HCT) is being increasingly used in acute leukemia patients as an alternative transplant modality when matched sibling or matched unrelated donors are unavailable. As several potential haploidentical relative donors are typically available for a given patient, optimizing donor selection to improve clinical outcome is crucial. The impact of donor age and kinship on the outcome of acute leukemia patients is not clearly established in this setting.Patients and methodsUsing the multinational registry of the acute leukemia working party of the European society for blood and marrow transplantation we retrospectively analyzed the clinical outcomes of adult acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) patients who underwent a first T-cell replete related haplo-HCT between 2005 and 2015.ResultsOur cohort comprised 1270 patients of which 1019 had AML and 251 had ALL. Seven hundred patients were transplanted at age 40 or over and 570 were transplanted at an age of less than 40. Median follow-up for patients in this analysis was 27 months (range 0.6-119 months). In multivariate analysis, patients over the age of 40 were significantly affected by increasing donor age resulting in higher non-relapse mortality (NRM) [Hazard ratio (HR)=1.86, confidence interval (CI) 95%, 1.18-2.94; P=0.007], inferior leukemia-free survival (LFS) (HR=1.59, CI 95%, 1.13-2.24; P=0.007), overall survival (OS) (HR=1.74, CI 95%, 1.22-2.47; P=0.002), and GVHD-free/relapse-free survival (GRFS) (HR=1.6, CI 95%, 1.16-2.22; P=0.004) rates when donors were over the age of 40. Whereas the relationship of the donor to the patient, namely sibling versus child donor, did not impact on patient outcome in a statistically significant manner, our results indicated that in the group of patients over 40 who were transplanted from their children, outcomes were less favorable when donors were over the age of 35. Specifically, this patient subset experienced an increased rate of NRM (HR=1.82, CI 95%, 1.13-2.9; P=0.01), inferior LFS (HR=1.5, CI 95%, 1.05-2.13; P=0.03) as well as inferior OS (HR=1.5, CI 95%, 1.04-2.15; P=0.03). For patients younger than 40 years of age, multivariate analysis revealed that having a donor over the age of 55 was independently associated with a decreased risk for extensive chronic GVHD (HR=0.16, CI 95%, 0.02-0.95; P=0.044) concomitant with a trend for an increased risk of relapse (HR=1.85, CI 95%, 0.97-3.49; P=0.058). The rates of NRM, OS, LFS, acute GVHD, and GRFS were not significantly impacted by donor age in this age group.ConclusionsOur data establish donor age and kinship as significant determinants of outcome following haplo-HCT for acute leukemia patients with potential implications for future donor selection algorithms in haplo-HCT. DisclosuresSavani:Jazz Pharmaceuticals: Speakers Bureau. Ciceri:GSK: Other: B-thalassemia gene therapy was developed by Fondazione Telethon and Ospedale San Raffaele and has been inlicenced by GSK that provides funding for the clinical trial, Research Funding. Mohty:Sanofi: Honoraria, Speakers Bureau.

Donor age determines outcome in acute leukemia patients over 40 undergoing haploidentical hematopoietic cell transplantation.

Haploidentical hematopoietic cell transplantation (haplo-HCT) is being increasingly used in acute leukemia patients as an alternative transplant modality when matched sibling or matched unrelated donors are unavailable. As several potential haploidentical relative donors are typically available for a given patient, optimizing donor selection to improve clinical outcome is crucial. The impact of donor age and kinship on the outcome of acute leukemia patients is not clearly established in this setting. Using the multinational registry of the acute leukemia working party of the European society for blood and marrow transplantation we retrospective analyzed the clinical outcome of 1270 acute myeloid leukemia and acute lymphoblastic leukemia patients who underwent haplo-HCT between 2005 and 2015. Patients over the age of 40 were significantly affected by increasing donor age resulting in higher non-relapse mortality (NRM) [Hazard ratio (HR)=1.86, confidence interval (CI) 95%, 1.18-2.94; P = .007], inferior leukemia-free survival (LFS) (HR = 1.59, CI 95%, 1.13-2.24; P = .007), and overall survival (OS) (HR = 1.74, CI 95%, 1.22-2.47; P = .002) when donors were over the age of 40. Additionally, kinship was found to be prognostically significant as patients transplanted from children donors over the age of 35 experienced an increased rate of NRM (HR = 1.82, CI 95%, 1.13-2.9; P = .01), inferior LFS (HR = 1.5, CI 95%, 1.05-2.13; P = .03), and OS (HR = 1.5, CI 95%, 1.04-2.15; P = .03). For patients younger than 40 years, donor age and kinship were mostly not clinically impactful. Our data establish donor age and kinship as significant determinants of outcome following haplo-HCT for acute leukemia patients.

The effect of margin status and molecular subtype on women with invasive breast cancer treated with breast-conservation therapy.

83 Background: A consensus statement was recently published by SSO/ASTRO on margins for stage I and II invasive breast cancer treated with breast conserving surgery (BCS). We examined patients with invasive breast cancer who underwent BCS to determine if margin status and molecular subtype influence outcomes. Methods: We the reviewed charts of 754 Stage I-III breast cancer patients treated with BCS from 2003-2010. Margin status was defined as negative ≥ 2mm, close &lt; 2mm and positive as tumor on ink. Conventional receptor analyses were used as markers for molecular subtype classification (luminal A, luminal B, Her2 positive, and basal). Clinicopathologic variables were tested using the Fisher’s exact, Chi-square, ANOVA F-test, and Kruskal-Wallis tests. A Cox proportional - Hazards model was used to measure the impact of these variables on locoregional recurrence (LRR), breast cancer-specific (BCSS) and overall survival (OS). Results: The median age of the cohort was 58 (range 27-89 years). Most were white (88%), had T1 tumors (76%), luminal A tumors (66%), invasive ductal histology (80%), and were node negative (76%). Of the 754 patients, 26% had close margins, 2% positive margins, and 9% unknown margins. With a median follow-up of 5.2 years, OS was 92%. Twenty eight patients had a LRR with a median time to recurrence of 5.1 years. On multivariate analysis, molecular subtype, pathologic grade (p=0.01), and use of radiation (p&lt;0.0001) were the only significant predictors of LRR. Unknown subtype, compared to Luminal A, was less likely to have a LRR (p=0.04). Basal (p=0.0002), Her2+ (p=0.03), Luminal B (p=0.002) and unknown subtype (p=0.04) had worse BCSS compared to Luminal A tumors. Margins had no impact on LRR or BCSS but those with close margins and unknown margins had worse OS compared to negative margins (p=0.01, p=0.007). Variables predictive of OS were margins, age, race, node status, chemotherapy, anti-endocrine therapy, and radiation. Conclusions: In this cohort treated with BCS, molecular subtype was a predictor of LRR and BCSS but not OS. Margin status did not impact LRR and BCSS. Although margin status was a predictor of OS, tumor biology remains the significant determinant of outcome.

Predictors of outcome in civilian gunshot wounds to the head

Civilian gunshot wounds to the head (GSWH) are often deadly, but some patients with open cranial wounds need medical and surgical management and are potentially good candidates for acceptable functional recovery. The authors analyzed predictors of favorable clinical outcome (Glasgow Outcome Scale scores of 4 and 5) after GSWH over a 24-month period. The authors posited 2 questions: First, what percentage of civilians with GSWH died in the state of Maryland in a given period of time? Second, what were the predictors of favorable outcome after GSWH? The authors examined demographic, clinical, imaging, and acute care data for 786 civilians who sustained GSWH. Univariate and logistic regression analyses were used to analyze the data. Of the 786 patients in this series, 712 (91%) died and 74 (9%) completed acute care in 9 trauma centers. Of the 69 patients admitted to one Maryland center, 46 (67%) eventually died. In 48 patients who were resuscitated, the Injury Severity Score was 26.2, Glasgow Coma Scale (GCS) score was 7.8, and an abnormal pupillary response (APR) to light was present in 41% of patients. Computed tomography indicated midline shift in 17%, obliteration of basal cisterns in 41.3%, intracranial hematomas in 34.8%, and intraventricular hemorrhage in 49% of cases. When analyzed for trajectory, 57.5% of bullet slugs crossed midcoronal, midsagittal, or both planes. Two subsets of admissions were studied: 27 patients (65%) who had poor outcome (25 patients who died and 2 who had severe disability) and 15 patients (35%) who had a favorable outcome when followed for a mean period of 40.6 months. Six patients were lost to follow-up. Univariate analysis indicated that admission GCS score (p < 0.001), missile trajectory (p < 0.001), surgery (p < 0.001), APR to light (p = 0.002), patency of basal cisterns (p = 0.01), age (p = 0.01), and intraventricular bleed (p = 0.03) had a significant relationship to outcome. Multivariable logistic regression analysis indicated that GCS score and patency of the basal cistern were significant determinants of outcome. Exclusion of GCS score from the regression models indicated missile trajectory and APR to light were significant in determining outcome. Admission GCS score, trajectory of the missile track, APR to light, and patency of basal cisterns were significant determinants of outcome in civilian GSWH.

Treatment outcome and prognostic indices in patients with hyperglycemic emergencies

ObjectiveThe objective of this study is to assess the treatment outcomes in patients with hyperglycemic emergencies and to ascertain the factors associated with outcome, with emphasis on the determinants of outcome.MethodA total of 105 patients admitted to the Accident and Emergency unit, who fulfilled the criteria for hyperglycemic emergencies, were selected. The information extracted included sociodemographic, clinical, and laboratory data, as well as hospitalization outcome.ResultsOf the 105 subjects that participated in the study, hyperosmolar hyperglycemic nonketotic state (HHNK) was seen in 50% (53) of the subjects, while diabetic ketoacidosis (DKA) was seen in 31% (29), normo-osmolar nonketotic hyperglycemic state (NNHS) in 12% (13), and mixed hyperglycemic emergency in 7% (10) of the subjects. The overall mortality rate in this study was 4.8%. Three deaths were recorded in patients with HHNK, while DKA and NNHS each had one death. Three of the deaths occurred within the first 24 hours of admission while the other two were more than 24 hours after admission. The mean (standard deviation) total duration of hospital stay was 24.2 days (SD), and the range of stay was 0.5–88 days.ConclusionThe most common type of hyperglycemic emergency seen in this study was HHNK. Also, the presence of infection, and sex of the study subject, were significant determinants of outcome in this study.

Clinical prognostic factors in pediatric Ewing sarcoma.

10052 Background: Treatment of Ewing sarcoma necessitates coordinated multi-disciplinary care that includes chemotherapy, surgery, and/or radiation. In developed countries, patients with localized disease have an overall survival of 70-80%, compared to 20-30% for those with metastases. The outcome of children with Ewing sarcoma in less developed countries has not been adequately described. We analyzed prognostic factors for Ewing sarcoma patients treated at a single institution in Lebanon, a developing country with available multidisciplinary treatment modalities. Methods: We reviewed characteristics and outcome of 42 pediatric patients treated at a multidisciplinary cancer center in Lebanon, between January 1999 and October 2012. Kaplan Meier curves were generated to estimate survival. Results: Median age at presentation was 10 years (range 1-18), and median follow-up was 41 months (range 8-110). Commonly affected primary sites included the extremity (36%, n=15), chest wall (19%, n=8), and pelvis (14%, n=6). Tumor size was ≥ 8cm in twenty (47.6%) patients. Thirty-two patients (76%) had localized disease, and ten (24%) had metastatic disease. All patients received 14 cycles of chemotherapy, with VDC alternating with IE. Local control was surgery alone (29%, n=12), radiotherapy alone (33%, n=14), or combination (38%, n=16). For patients with localized disease, the 5-year OS and DFS rates were 68% and 55% respectively, while for metastatic disease they were 28% and 25%. Tumor recurrence was local in 8 patients, distant in 8, and combined in 2. Factors associated with improved outcome included localized disease, extremity site, surgery, and timely local control. In multivariate analysis, timing of local control and metastatic disease were prognostically significant determinants of outcome. Conclusions: Treatment of childhood Ewing sarcoma in a multidisciplinary cancer center in Lebanon results in similar survival to that in developed countries when similar protocols are applied. Strong prognostic factors included stage (localized vs. metastatic), and timing of local control. Patients who had a local control time delay of more than 3 weeks fared worse, strongly suggesting that delays in local control should be actively minimized in Ewing sarcoma.

Outcome of Neonates with Ebstein’s Anomaly in the Current Era

Ebstein's anomaly is frequently detected before birth, with prenatal detection accounting for the majority of cases in the current population. This study aimed to identify the outcome variables among these infants. The medical records of 59 patients with neonatal Ebstein's anomaly managed at the Asan Medical Center between January, 2001 and June, 2012 were investigated retrospectively. In 46 cases, the diagnosis was made prenatally. Surgical/interventional procedures were performed for 27 of the analyzed patients. Biventricular repair was successful for 12 patients but not for 9 patients with pulmonary atresia. The median follow-up period was 1.96 years (range 0.0-10.4 years). The overall mortality rate was 23.7 % (14/59). Of the 14 deaths, 5 occurred within several hours after birth. The 1- and 5-year survival rates were 78.6 and 76.3 %, respectively. Univariate analysis identified several variables related to the time to death: fetal distress (p = 0.002), prematurity (p = 0.036), low birth weight (p = 0.003), diameter of the atrial septal defect (p = 0.022), and pulmonary stenosis/atresia (p = 0.001). Neither the Carpentier classification (p = 0.175) nor the Celermajer index (p = 0.958) was a significant variable. According to the multivariate analysis, fetal distress (p = 0.004) and pulmonary atresia/stenosis (p < 0.001) were significant determinants of outcome. In conclusion, fetal distress and pulmonary atresia/stenosis are significant predictors of mortality in the current population of patients with neonatal Ebstein's anomaly. A close cooperation of associated clinicians is required for an improvement in outcome. To establish a better surgical strategy for patients with Ebstein's anomaly and pulmonary atresia, studies of larger populations are required.

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Introduction: Myocardial dysfunction has not been evaluated in children with septic shock despite the assumption that it is a significant determinant of outcome when compared to adults. Hypothesis: Its prevalence in adults with septic shock is 40-60%, but its prevalence in children is not known. Methods: Thirty patients with fluid refractory septic shock were prospectively studied by echo <24 hours after admission to the pediatric intensive care unit (PICU). Evaluation included measures of left ventricular (LV) size and function, mitral valve (MV) inflow velocities in early (E) and late (A) diastole, MV annular velocities in systole (s’) and early (e’) and late (a’) diastole, and MV annular acceleration during isovolumic contraction (IVA). LV myocardial performance index (MPI) to assess combined systolic/diastolic function was calculated as the sum of isovolumic contraction and relaxation times divided by ejection time. All data were compared to normal children using Z scores. LV systolic dysfunction was defined as ejection fraction or shortening fraction Z score <-2. LV diastolic dysfunction was defined as E/e’ Z score >2. Measured secondary outcomes included vasoactive inotropic score (VIS), troponin, acute kidney injury (pediatric RIFLE score), and 28-day mechanical ventilation free duration. Results: Mortality for the 30 patients (mean 9.5 ± 7 yrs; range 10 days-21 yrs) was 7%. The prevalence of LV systolic and/or diastolic dysfunction was 53% (16/30). Eleven (37%) had systolic dysfunction; 10 (33%) had diastolic dysfunction; 5 (17%) had both. Systolic dysfunction was significantly associated with IVA (P = 0.05), s’ Z score <-2 (P= 0.005), and MPI Z score >2 (P= 0.03). Systolic and/or diastolic dysfunction was also significantly associated with VIS (P=0.006), troponin (P=0.007), and RIFLE score (P=0.02) but not with ventilation free duration (P= 0.12). Kaplan Meier analysis for duration of PICU and hospital stay was not different between those with and without dysfunction. Conclusions: The prevalence of myocardial dysfunction is similar in children and adults with septic shock. Although myocardial dysfunction is associated with some measures of poor clinical outcome, it does not affect PICU and hospital length of stay.

Improving case fatality rate of adult tetanus in urban Nigeria: focus on better facilities of care

Tetanus is a life threatening preventable infection with a high mortality. Our aim was to determine the current case fatality rate at our centre in a retrospective case review of patients aged > 10 years who had been hospitalized with tetanus between August 2006 and July 2011. We show the intrahospital case fatality rate. Data are based on 176 cases for which we had sufficient information. There was a preponderance of males (3.09:1); 167 (95%) had generalized tetanus and nine (5%) had localized tetanus. The overall case fatality rate was 56.2% and was higher in males (64.4%) than females (27.9%; P = 0.0001). In a multivariate analysis, older age (P = 0.000), male gender (P = 0.005) and a longer duration of admission (P = 0.004) were significant determinants of outcome. The case fatality rate of tetanus has declined at our centre from 70% between January 2004 and March 2006 to 56.2% currently. Improved facilities are required in order to significantly reduce adverse outcome from tetanus.

Usefulness of Pre-Operative Copeptin Concentrations to Predict Post-Operative Outcome After Major Vascular Surgery

The aim of this study was to investigate whether preoperative determination of plasma copeptin levels in addition to plasma N-terminal pro–B-type natriuretic peptide (NT–pro-BNP) could help improve risk stratification in patients who undergo major vascular surgery. One hundred ninety-eight consecutive patients who underwent major vascular surgery (58.6% infrainguinal aortic reconstruction, 23.7% abdominal aortic aneurysm surgery, 17.7% carotid endarterectomy) were included in this study. Patients were monitored for in-hospital and long-term (2-years) major adverse cardiac events, consisting of cardiac death, nonfatal myocardial infarction, and emergent coronary revascularization. Overall, 40 patients (20.2%) reached the primary end point, and most of these events occurred during the index hospital stay (n 18 [45%]). In univariate Cox regression analysis, increasing concentrations of copeptin were significant determinants of outcome as a continuous variable (hazard ratio [HR] 1.012, p 0.005) and as a dichotomized variable according to the recommended cutoff of 14.0 pmol/L (HR 4.116, p 14 pmol/L were significant independent predictors of outcome (HR 2.842, p 0.002) in addition to type of surgery, history of myocardial infarction, elevated levels of cardiac troponin T, and NT–pro-BNP levels. In conclusion, the results of this study suggest that preoperative determination of this new biomarker could substantially improve prediction of perioperative and postoperative outcomes in vascular surgery patients. © 2011 Elsevier Inc. All rights reserved. (Am J Cardiol 2011;108:1188 –1195)