scholarly journals Longer than 2 hours to antibiotics is associated with doubling of mortality in a multinational community-acquired bacterial meningitis cohort

2022 ◽  
Vol 12 (1) ◽  
Author(s):  
Damon P. Eisen ◽  
Elizabeth Hamilton ◽  
Jacob Bodilsen ◽  
Rasmus Køster-Rasmussen ◽  
Alexander J. Stockdale ◽  
...  

AbstractTo optimally define the association between time to effective antibiotic therapy and clinical outcomes in adult community-acquired bacterial meningitis. A systematic review of the literature describing the association between time to antibiotics and death or neurological impairment due to adult community-acquired bacterial meningitis was performed. A retrospective cohort, multivariable and propensity-score based analyses were performed using individual patient clinical data from Australian, Danish and United Kingdom studies. Heterogeneity of published observational study designs precluded meta-analysis of aggregate data (I2 = 90.1%, 95% CI 71.9–98.3%). Individual patient data on 659 subjects were made available for analysis. Multivariable analysis was performed on 180–362 propensity-score matched data. The risk of death (adjusted odds ratio, aOR) associated with treatment after two hours was 2.29 (95% CI 1.28–4.09) and increased substantially thereafter. Similarly, time to antibiotics of greater than three hours was associated with an increase in the occurrence of neurological impairment (aOR 1.79, 95% CI 1.03–3.14). Among patients with community-acquired bacterial meningitis, odds of mortality increase markedly when antibiotics are given later than two hours after presentation to the hospital.

2021 ◽  
Author(s):  
Ashwin Subramaniam ◽  
Christopher Anstey ◽  
J Randall Curtis ◽  
Sushma Ashwin ◽  
Mallikarjuna PONNAPA REDDY ◽  
...  

Abstract Purpose: Frailty is often used in clinical decision-making for patients with COVID-19, yet studies have found variable influence of frailty on outcomes in those admitted to the intensive care unit (ICU). In this individual patient data meta-analysis, we evaluated the characteristics, and outcomes of frail patients admitted to ICU with COVID-19.Methods: We contacted the corresponding authors of sixteen eligible studies published between December 1st 2019 and February 28th 2021 reporting the clinical frailty scale (CFS) in patients with confirmed COVID-19 admitted to ICU. Individual patient data was obtained from 7 studies. We classified patients as non-frail (CFS=1-4) or frail (CFS=5-8). The primary outcome was hospital mortality. We also compared the use of mechanical ventilation (MV) and the proportion of ICU bed-days between frailty categories. Results: Of the 2001 patients admitted to ICU, 388 (19.4%) were frail. Increasing age and sequential organ failure assessment (SOFA) score, CFS ≥4, use of MV, vasopressors, renal replacement therapy and hyperlactatemia were risk factors for death in a multivariable analysis. Hospital mortality was higher in frail patients (65.2% vs. 41.8%; p<0.001), with adjusted mortality increasing with a rising CFS score beyond 3. Younger and non-frail patients were more likely to receive MV. Frail patients spent less time on MV (median days [IQR] 9 [5-16] vs. 11 [6-18]; p=0.012) and accounted for only 12.3% of total ICU bed-days. Conclusion: Frail patients with COVID-19 were commonly admitted to ICU and had greater hospital mortality but spent relatively fewer days in ICU when compared with non-frail patients. Frail patients receiving MV were at greater risk of death than non-frail patients. Systematic review registration: Registration protocol in PROSPERO (CRD42020224255).


2020 ◽  
Vol 22 (Supplement_3) ◽  
pp. iii281-iii281
Author(s):  
Reena M Underiner ◽  
Mostafa Eltobgy ◽  
Joseph R Stanek ◽  
Jonathan L Finlay ◽  
Mohamed S AbdelBaki

Abstract BACKGROUND Metastatic atypical teratoid/rhabdoid tumors (AT/RT) are aggressive central nervous system tumors that present during infancy and are associated with dismal outcomes. Patients receive multimodal treatment including surgical resection, systemic chemotherapy and one or more of intrathecal chemotherapy (IT), marrow-ablative chemotherapy with autologous hematopoietic cell rescue (AuHCR) and radiation therapy (XRT). While data regarding treatment modalities for AT/RT patients exist, no comprehensive data have been published regarding the metastatic patient population. METHODS We performed a meta-analysis of 1,578 articles published through September 2018, including 44 studies with a total of 123 subjects. Additionally, seven patients were incorporated through chart review of patients treated at Nationwide Children’s Hospital. RESULTS Analysis of 130 patients revealed a 3-year overall survival (OS) of 25%. Age at diagnosis had a significant impact on survival (p=0.0355); 3-year OS for infants &lt; 18 months was 21%; 18–36 months was 26%; and &gt; 36 months was 36%. Location of the primary tumor, metastatic stage and extent of surgical resection did not have significant impact on OS. On univariate analysis, XRT (p&lt;0.0001), IT (p=0.01) and AuHCR (p&lt;0.0001) were found to significantly improve survival. The most substantial effect was noted in patients who received AuHCR (3-year OS of 60% versus 9% in those who did not). On multivariable analysis XRT (p=0.0006), IT (p=0.0124) and AuHCR (p&lt;0.0001) were independently associated with reduced risk of death.


Gut ◽  
2021 ◽  
pp. gutjnl-2020-323663
Author(s):  
Victor Sapena ◽  
Marco Enea ◽  
Ferran Torres ◽  
Ciro Celsa ◽  
Jose Rios ◽  
...  

ObjectiveThe benefit of direct-acting antivirals (DAAs) against HCV following successful treatment of hepatocellular carcinoma (HCC) remains controversial. This meta-analysis of individual patient data assessed HCC recurrence risk following DAA administration.DesignWe pooled the data of 977 consecutive patients from 21 studies of HCV-related cirrhosis and HCC, who achieved complete radiological response after surgical/locoregional treatments and received DAAs (DAA group). Recurrence or death risk was expressed as HCC recurrence or death per 100 person-years (100PY). Propensity score-matched patients from the ITA.LI.CA. cohort (n=328) served as DAA-unexposed controls (no-DAA group). Risk factors for HCC recurrence were identified using random-effects Poisson.ResultsRecurrence rate and death risk per 100PY in DAA-treated patients were 20 (95% CI 13.9 to 29.8, I2=74.6%) and 5.7 (2.5 to 15.3, I2=54.3), respectively. Predictive factors for recurrence were alpha-fetoprotein logarithm (relative risk (RR)=1.11, 95% CI 1.03 to 1.19; p=0.01, per 1 log of ng/mL), HCC recurrence history pre-DAA initiation (RR=1.11, 95% CI 1.07 to 1.16; p<0.001), performance status (2 vs 0, RR=4.35, 95% CI 1.54 to 11.11; 2 vs 1, RR=3.7, 95% CI 1.3 to 11.11; p=0.01) and tumour burden pre-HCC treatment (multifocal vs solitary nodule, RR=1.75, 95% CI 1.25 to 2.43; p<0.001). No significant difference was observed in RR between the DAA-exposed and DAA-unexposed groups in propensity score-matched patients (RR=0.64, 95% CI 0.37 to 1.1; p=0.1).ConclusionEffects of DAA exposure on HCC recurrence risk remain inconclusive. Active clinical and radiological follow-up of patients with HCC after HCV eradication with DAA is justified.


Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 936-936
Author(s):  
Richard H. White ◽  
Ann Brunson ◽  
Gwendolyn Ho ◽  
Ted Wun

Abstract Background Evidence supporting use of an inferior vena cava filter (VCF) to prevent death or recurrent venous thromboembolism (rVTE) in cancer patients who are hospitalized for acute VTE is limited. Aims To determine the effectiveness of VCF placement on the 15-day and 30-day incidence of death and the 180-day incidence of rVTE manifested as pulmonary embolism (PE) or recurrent deep-vein thrombosis (DVT) alone among cancer patients hospitalized for acute-VTE. Methods Using a large retrospective observational study of discharge records in California, we analyzed outcomes after VCF placement in cancer patients hospitalized 2005-2009 for acute VTE using propensity-score methodology. We excluded all patients who had a history of a prior VCF placement (1991-2009). Outcomes were death <15-days and <30-days and rVTE (as PE or DVT alone) at 6 months. We used 3 analytic methods: 1) standard risk-adjusted multivariable analysis, 2) adjustment using propensity-score and inverse probability weighing (IPW) and 3) comparison based on matching (2:1) based on propensity score (caliper method). The multivariate model used to generate the propensity score included age, race/ethnicity, insurance coverage, expected bleeding risk, metastatic disease, bleeding present-on-admission, location of bleeding, recent or impending major surgery, use of thrombolytic agents, number of chronic co-morbidities, severity-of-illness (ascertained by 3M, APR-DRG grouper), index PE vs. DVT, and hospital characteristics. IPW of propensity score was applied to a risk-adjusted logistic model to predict death; IPW was applied to risk-adjusted Cox models predicting rVTE (as PE or DVT alone). In the model predicting death, risk-of-mortality on admission was used instead of severity-of-illness. Results Among 14,000 cancer-associated acute-VTE cases, the overall crude 15-day mortality rate was 1396 (10%) and the 30-day mortality was 2247 (16.1%). For 11,253 no-VCF patients, the crude 15-day mortality was 1089 (9.7%) and at 30 days it was 1727 (15.3%). A VCF was placed in 2747 patients (19.6%). The crude mortality in VCF patients was 307 (11.2%) at 15-days, and 520 (18.9%) at 30-days. After accounting for propensity to insert a VCF (using IPW) in a risk-adjusted model, there was no significant reduction in the risk of death associated with VCF use at 15-days (OR=0.90, CI:0.8-1.1, p=0.26) or 30 days (OR=1.04, 95%CI:0.9-1.2, p=0.57); findings were the same using standard multivariable analysis and matching based on propensity score. The crude 180-day incidence of recurrent PE was 3.3%: 2.6% in VCF patients and 3.4% in the no-VCF patients. In the adjusted model using IPW the risk of rVTE manifested as PE, the risk was lower in VCF patients (HR=0.81 95%CI:0.6-1.1, p=0.14) but this did not reach statistical significance. The crude 180-day incidence of rVTE manifested as DVT alone was 4.2% overall: 5.4% in VCF patients and 3.9% in no-VCF patients. In the IPW propensity score model, the risk of rVTE manifested as DVT at 180 days was significantly higher in VCF patients (HR=1.55, 95%CI:1.3-1.9, p<0.001). Models for recurrent VTE manifested by PE or DVT gave similar results whether based on propensity-score matching or multivariable analysis. Conclusions Use of a VCF in cancer patients hospitalized specifically for acute VTE was not associated with a significant reduction in the risk of death at 15 or 30 days, and the overall 30-day mortality was high. There was a 20% reduction in the risk of rVTE manifested as PE at 180-days but this did not reach the level of statistical significance (p>0.05). VCF use was associated with a 55% higher risk of rVTE manifested as DVT at 180 days. Further refinements in modeling incorporating competing outcomes (e.g., death) are underway. Disclosures: Ho: American Society of Hematology: ASH HONORS trainee research award Other.


2020 ◽  
Vol 8 (1) ◽  
Author(s):  
Bing-Cheng Zhao ◽  
Wei-Feng Liu ◽  
Shao-Hui Lei ◽  
Bo-Wei Zhou ◽  
Xiao Yang ◽  
...  

Abstract Background The clinical significance of cardiac troponin measurement in patients hospitalised for coronavirus disease 2019 (covid-19) is uncertain. We investigated the prevalence of elevated troponins in these patients and its prognostic value for predicting mortality. Methods Studies were identified by searching electronic databases and preprint servers. We included studies of hospitalised covid-19 patients that reported the frequency of troponin elevations above the upper reference limit and/or the association between troponins and mortality. Meta-analyses were performed using random-effects models. Results Fifty-one studies were included. Elevated troponins were found in 20.8% (95% confidence interval [CI] 16.8–25.0 %) of patients who received troponin test on hospital admission. Elevated troponins on admission were associated with a higher risk of subsequent death (risk ratio 2.68, 95% CI 2.08–3.46) after adjusting for confounders in multivariable analysis. The pooled sensitivity of elevated admission troponins for predicting death was 0.60 (95% CI 0.54–0.65), and the specificity was 0.83 (0.77–0.88). The post-test probability of death was about 42% for patients with elevated admission troponins and was about 9% for those with non-elevated troponins on admission. There was significant heterogeneity in the analyses, and many included studies were at risk of bias due to the lack of systematic troponin measurement and inadequate follow-up. Conclusion Elevated troponins were relatively common in patients hospitalised for covid-19. Troponin measurement on admission might help in risk stratification, especially in identifying patients at high risk of death when troponin levels are elevated. High-quality prospective studies are needed to validate these findings. Systematic review registration PROSPERO CRD42020176747


2010 ◽  
Vol 9 (3) ◽  
pp. 254-263 ◽  
Author(s):  
Diederik van de Beek ◽  
Jeremy J Farrar ◽  
Jan de Gans ◽  
Nguyen Thi Hoang Mai ◽  
Elizabeth M Molyneux ◽  
...  

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