Etomidate, Adrenal Insufficiency and Mortality Associated With Severity of Illness: A Meta-Analysis

2020 ◽  
pp. 088506662095759
Author(s):  
Stewart G. Albert ◽  
Sujata Sitaula
Keyword(s):  
Critical Illness ◽  
Mortality Rate ◽  
Adrenal Insufficiency ◽  
Absolute Risk ◽  
Meta Analysis ◽  
Severity Of Illness ◽  
Mortality Rates ◽  
Secondary Outcome ◽  
Relative Mortality ◽  
Cochrane Reviews

Purpose: Etomidate causes adrenal insufficiency. Yet in critically ill patients, it is controversial whether it increases mortality rates above that of comparator anesthetic induction agents. We postulated that etomidate would increase relative mortality rates correspondingly to the severity of illness as defined by SAPS or APACHE scores. Materials and Methods: A literature search was performed on Pub Med, SCOPUS, and Cochrane Reviews for human studies, regardless of language, between 1983 and February 2020. The search strategy used keywords, “etomidate,” “adrenal insufficiency,” “glucocorticoid,” and “intensive care.” Both authors reviewed electronic data search titles, abstracts and extracted data, which were checked by the other reviewer. Primary outcome was 28-day survival. Secondary outcome was adrenal insufficiency. Results: There were 29 trials of etomidate versus comparators in 8584 patients. Etomidate was associated with adrenal insufficiency (risk ratio (rr) = 1·54, 95% CI; 1·42, 1·67, p < 0.001) and increased overall relative mortality rates (rr = 1.09, CI;1.04,1.16, p = 0.001). Meta-regression showed that with etomidate there was a continuous progressive relative risk of mortality associated with increasing severity of illness (predefined in each article by standard critical illness scores). In those patients who had a predicted mortality rate > the median for this analysis (predicted mortality 44%) the relative mortality rate (rr) = 1.20, Ci;1.12,1.29, p < 0.001, the absolute risk difference (rd) = 0.08, CI;0.05,0.11, p < 0.0001 and the number needed to harm (1/rd) was 12.5. In those with a calculated predicted mortality <44% there was no increase in relative mortality rate. Conclusions: Whereas etomidate causes adrenal insufficiency, it was not shown to increase mortality in many analyzed here in ICU settings. However, etomidate associated relative mortality rates increased progressively and correlated with the severity of critical illness scores. Intensivists should anticipate the need for glucocorticoid supplementation after etomidate in those with severe critical illness and in those with acute deterioration of vital signs.

Critical illness myopathy in intensive care setting

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
Mostafa K Fouad ◽  
Ashraf M Hazem ◽  
Kareem M Elnaghy
Keyword(s):  
Critical Illness ◽  
Mortality Rate ◽  
Usual Care ◽  
Usual Care Group ◽  
Fixed Effects ◽  
Meta Analysis ◽  
Care Group ◽  
Fixed Effects Model ◽  
Analysis Study ◽  
Number Of Patients

Abstract Aim of the Work to provide cumulative data about the efficacy and safety of neuro-muscular electrical stimulation (NMES) combined with usual care (UC) versus usual care alone in ICU patients with Critical Illness Myopathy (CIM). Methodology The current systematic review was done on studies published between 2009 and 2019. The total number of patients in all the included studies was 1259 patients; 652 in NMES group, and 607 in UC group. Our data were divided into two groups: NMES (652 patients), and UC (607 patients). Metaanalysis study was done on 11 studies which described and compared the 2 different techniques for treatment of CIM; with overall number of patients (N = 1259). Results Regarding 1ry outcome measures, we found 8 studies reported critical Critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and the overlap, critical care setting   MRC scale for muscle strength, with total number of patients (N = 968). The random-effects model of the meta-analysis study showed non-significant difference in mean MRC scale in NMES group compared to usual care group (p &gt; 0.05). We also found 11 studies reported ICU stay with total number of patients (N = 1259). The random-effects model of the meta-analysis study showed nonsignificant difference in mean ICU stay in NMES group compared to usual care group (p &gt; 0.05). We also found only 2 studies reported SF-36 scale for quality of life, with total number of patients (N = 270). The fixed-effects model of the metaanalysis study showed highly significant decrease in mean SF-36 scale in NMES group compared to usual care group (p = 0.003). Regarding 2ry outcome measure, we found 3 studies reported CIM incidence with total number of patients (N = 394). The fixed-effects model of the meta-analysis study showed marked decrease in CIM incidence in NMES group compared to usual care group, but not reaching statistical significance (p &gt; 0.05). We also found 9 studies reported mortality rate with total number of patients (N = 1044). The fixed-effects model of the meta-analysis study showed non-significant difference in mortality rate in NMES group compared to usual care. Our systematic review and meta-analysis showed that NMES combined with usual care was not associated with significant differences in global muscle strength, ICU stay, quality of life score, CIM incidence and mortality rate in comparison with usual care alone in critically ill patients. Conclusion NMES is not superior to usual care in management of CIM. Usual care remains the mainstay of management of CIM with significant better outcomes, in addition to preventive measures as early aggressive treatment of sepsis and MOF, blood glucose control, optimizing certain drugs use, early enteral nutrition, maintaining water, electrolyte and acidbase balance.

scholarly journals The effect of double-carbapenem therapy on mortality rates and microbiological cure rates in patients diagnosed with carbapenem-resistant Klebsiella pneumoniae infections in comparison to monotherapy and currently used combinations of antibiotics

2021 ◽  
Vol 5 (1) ◽  
pp. e000243
Author(s):  
Rhiannon Olivia Moody
Keyword(s):  
Mortality Rate ◽  
Klebsiella Pneumoniae ◽  
Therapeutic Option ◽  
Meta Analysis ◽  
Mortality Rates ◽  
Resistant Bacteria ◽  
Cure Rate ◽  
Treatment Regimens ◽  
Hospitalised Patients ◽  
Microbiological Cure

Introduction: Infection with the bacteria carpamenease-producing Klebsiella pneumoniae represents a significant cause of mortality in hospitalised patients. These multidrug resistant bacteria are resistant to currently used antibiotics as a result of carbapenemase production. Dual carbapenem therapy has been proposed as a valid therapeutic option, this therapy combines two carbapenem antibiotics, with one acting as a suicide inhibitor allowing the subsequent carbapenem to exert a bactericidal effect. Aim: The aim of this meta-analysis was to determine if dual carbapenem therapy had a significant effect on mortality rate and microbiological cure rate in patients diagnosed with carbapenemase-producing Klebsiella pneumoniae infections in comparison to standard antibiotic therapies. Methods: The search terms “(dual OR double) carbapenem (therapy OR treatment) AND klebsiella pneumoniae” were used to search databases and inclusion and exclusion criteria were applied to retrieved papers, a total of seven studies were identified for inclusion in the meta-analysis. The quality of included studies was assessed using the cochrane tool for risk of bias assessment and funnel plots were produced to determine the influence of publication bias. A random effects model was used to assess the outcomes; mortality rate and microbiological cure rate. Results and Conclusion: Dual carbapenem therapy had a time dependent effect on patient mortality rates. Dual carbapenem therapy significantly lowered  mortality rates in patients in comparison to standard antibiotic therapy, especially in comparison to monotherapy treatment regimens. Additionally, dual carbapenem therapy significantly improved microbiological cure rate in patients when compared to standard antibiotic treatment regimens demonstrating the possible clinical applications of a dual carbapenem antibiotic regimen in the treatment of carbapenemase-producing Klebsiella pneumoniae infections. 

Risk of mortality and reoperation in hip fracture patients undergoing cemented versus uncemented hemiarthroplasty

2022 ◽  
Vol 104-B (1) ◽  
pp. 127-133
Author(s):  
Bjarke Viberg ◽  
Alma B. Pedersen ◽  
Anders Kjærsgaard ◽  
Jens Lauritsen ◽  
Søren Overgaard
Keyword(s):  
Hip Fracture ◽  
Absolute Risk ◽  
Population Based ◽  
Risk Difference ◽  
Secondary Outcome ◽  
Relative Mortality ◽  
Hazard Ratios ◽  
Risk Of Mortality ◽  
Uncemented Hemiarthroplasty

Aims The aim of this study was to assess the association of mortality and reoperation when comparing cemented and uncemented hemiarthroplasty (HA) in hip fracture patients aged over 65 years. Methods This was a population-based cohort study on hip fracture patients using prospectively gathered data from several national registries in Denmark from 2004 to 2015 with up to five years follow-up. The primary outcome was mortality and the secondary outcome was reoperation. Hazard ratios (HRs) for mortality and subdistributional hazard ratios (sHRs) for reoperations are shown with 95% confidence intervals (CIs). Results A total of 17,671 patients with primary HA were identified (9,484 uncemented and 8,187 cemented HAs). Compared to uncemented HA, surgery with cemented HA was associated with an absolute risk difference of 0.4% for mortality within the period zero to one day after surgery and an adjusted HR of 1.70 (95% CI 1.22 to 2.38). After seven days, there was no longer any association, with an adjusted HR of 1.07 (95% CI 0.90 to 1.28). This continued until five years after surgery with a HR of 1.01 (95% CI 0.96 to 1.06). There was a higher proportion of reoperations due to any reason after five years in the uncemented group with 10.2% compared to the cemented group with 6.1%. This yielded an adjusted sHR of 0.65 (95% CI 0.57 to 0.75) and difference continued up until five years after the surgery, demonstrating a sHR of 0.70 (95% CI 0.59 to 0.83). Conclusion In a non-selected cohort of hip fracture patients, surgery with cemented HA was associated with a higher relative mortality during the first postoperative day compared to surgery with uncemented HA, but there was no difference after seven days up until five years after. In contrast, surgery with cemented HA was associated with lower risk of reoperation up to five years postoperatively compared with surgery with uncemented HA. There was a higher relative mortality on the first postoperative day for cemented HA versus uncemented HA. There was no difference in mortality after seven days up until five years after surgery. There were 6.1% reoperations for cemented HA compared to 10.2% for uncemented HA after five years. Cite this article: Bone Joint J 2022;104-B(1):127–133.

scholarly journals Safety and efficacy of the European Society of Cardiology 0/1-hour algorithm for diagnosis of myocardial infarction: systematic review and meta-analysis

Heart ◽  
2020 ◽  
Vol 106 (13) ◽  
pp. 985-991 ◽  
Author(s):  
Cho-Han Chiang ◽  
Cho-Hung Chiang ◽  
Gin Hoong Lee ◽  
Weng-Tein Gi ◽  
Yuan-Kun Wu ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Mortality Rate ◽  
European Society ◽  
Primary Outcome ◽  
Meta Analysis ◽  
High Sensitivity ◽  
Secondary Outcome ◽  
Cochrane Central Register ◽  
Registration Number ◽  
European Society Of Cardiology

ObjectiveThe European Society of Cardiology (ESC) 0/1 hour algorithm has been primarily validated in Europe, America and Australasia with less knowledge of its performance outside of these settings. We aim to evaluate the performance of the ESC 0/1 hour algorithm across different contexts.MethodsWe searched PubMed, Embase, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials for relevant studies published between 1 January 2008 and 31 May 2019. The primary outcome was index myocardial infarction and the secondary outcome was major adverse cardiac event or mortality. A bivariate random-effects meta-analysis was used to derive the pooled estimate of each outcome.ResultsA total of 11 014 patients from 10 cohorts were analysed for the primary outcome. The algorithm based on high-sensitivity cardiac troponin (hs-cTn)T (Roche), hs-cTnI (Abbott) and hs-cTnI (Siemens) had pooled sensitivity of 98.4% (95% CI=95.1% to 99.5%), 98.1% (95% CI=94.6% to 99.3%) and 98.7% (95% CI=97.3% to 99.3%), respectively. The algorithm based on hs-cTnT (Roche) and hs-cTnI (Siemens) had pooled specificity of 91.2% (95% CI=86.0% to 94.6%) and 95.9% (95% CI=94.1% to 97.2%), respectively. Among patients in the rule-out category, the pooled mortality rate at 30 days and at 1 year was 0.1% (95% CI=0.0% to 0.4%) and 0.8% (95% CI=0.5% to 1.2%), respectively. Among patients in the observation zone, the pooled mortality rate was 0.7% (95% CI=0.3% to 1.2%) at 30 days but increased to 8.1% (95% CI=6.1% to 10.4%) at 1 year, comparable to the mortality rate in the rule-in group.ConclusionThe ESC 0/1 hour algorithm has high diagnostic accuracy but may not be sufficiently safe if the 1% miss-rate for myocardial infarction is desired.PROSPERO registration numberCRD42019142280.

scholarly journals Timing of Renal Replacement Therapy Initiation in Patients with Septic Acute Kidney Injury; A Systematic Review and Meta-Analysis

2021 ◽  
Author(s):  
Hyung Jung Oh ◽  
In Kyung Min ◽  
Yun Ho Roh ◽  
Jung ho Kim ◽  
Jin Young Ahn ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Renal Replacement Therapy ◽  
Mortality Rate ◽  
Replacement Therapy ◽  
Meta Analysis ◽  
Kidney Injury ◽  
Mortality Rates ◽  
Treated Group ◽  
Optimal Timing ◽  
Late Group

Abstract Background; Acute kidney injury (AKI) is the most frequent complication seen in patients with septic shock and is an independent risk factor for death. Although renal-replacement therapy (RRT) is standard care for patients with severe septic AKI, the optimal timing of RRT initiation remains controversial.Methods; The PubMed, Cochrane, and Embase databases were searched from their inception to June 2021 to identify the ideal timing of RRT initiation in patients with septic AKI by comparing 28- and 90-day mortality rates.Results; Among a total of six studies including 1,058 patients, the 28-day mortality rate was significantly lower in the early RRT-treated group compared to the late group [RR=0.69; 95% CI (0.51-0.94); P=0.018]. Moreover, among the five studies including 938 patients, the 90-day mortality rate was also significantly lower in the early RRT-treated group than the late group [RR=0.61; 95% CI (0.47-0.80); P=0.01]. In a subgroup analysis for continuous RRT (CRRT), we also found significantly lower 28- and 90-day mortality rates in the early CRRT-treated group compared to the late group.Conclusion; This study showed that early initiation of RRT might reduce 28- and 90-day mortality compared with late initiation in septic AKI patients.

scholarly journals Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Femke Nawijn ◽  
Diederik P. J. Smeeing ◽  
Roderick M. Houwert ◽  
Luke P. H. Leenen ◽  
Falco Hietbrink
Keyword(s):  
Surgical Treatment ◽  
Soft Tissue ◽  
Mortality Rate ◽  
Meta Analysis ◽  
Operating Time ◽  
Mortality Rates ◽  
Soft Tissue Infections ◽  
Included Patient ◽  
Necrotizing Soft Tissue Infections ◽  
Analysis Models

Abstract Background Although the phrase “time is fascia” is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs. Methods A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models. Result A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26–0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27–0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively. Conclusion Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI.

scholarly journals P054 Risk of death during the 2020 UK COVID-19 epidemic among people with rare diseases compared to the general population

Rheumatology ◽  
2021 ◽  
Vol 60 (Supplement_1) ◽  
Author(s):  
Megan Rutter ◽  
Peter C Lanyon ◽  
Emily Peach ◽  
Matthew J Grainge ◽  
Richard B Hubbard ◽  
...  
Keyword(s):  
General Population ◽  
Rare Diseases ◽  
Absolute Risk ◽  
Healthcare Services ◽  
Mortality Rates ◽  
Baseline Risk ◽  
Secondary Outcome ◽  
Published Data ◽  
Risk Of Death ◽  
Increased Risk

Abstract Background/Aims  To quantify the risk of death among people with rare autoimmune rheumatic diseases (RAIRD) during the UK 2020 COVID-19 epidemic compared with baseline risk and the risk of death in the general population during COVID-19. Methods  A cohort study was performed using data from the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS). Coded diagnoses for RAIRD were identified from Hospital Episode Statistics from 2003 onwards. Previous coding validation work demonstrated our case ascertainment methods had a positive predictive value &gt;85%. ONS published data were used for general population mortality rates. The main outcome measure was age-standardised mortality rates (ASMRs) for all-cause death. Secondary outcome measures were age-sex standardised mortality rates, and age-stratified mortality rates. Results  168,691 people with RAIRD were alive on 1 March 2020. Their median age was 61.7 (IQR 41.5-75.4) years, and 118,379 (70.2%) were female. 1,815 (1.1%) people with RAIRD died during March and April 2020. The ASMR among people with RAIRD was 3669.3 (95% CI 3500.4-3838.1) per 100,000 person-years, which was 1.44 (95% CI 1.42-1.45) times higher than the average ASMR during the same months of the previous 5 years. In the whole population of England, the ASMR during March and April 2020 was 1361.1 (1353.6- 1368.7) per 100,000 people, which was 1.38 times higher than the average ASMR during the same months of the previous 5 years (see related abstract about influenza seasons). Unlike in the general population, sex-specific rates in RAIRD were similar in males and females. When comparing risk of death during COVID-19 to pre-COVID-19, people with RAIRD had an increased risk of death from age 35 upwards, compared to around age 55 upwards in the general population. As the protective effect of being female was not seen in RAIRD, the group at the largest increased risk compared to their pre-COVID-19 risk were women aged 35 upwards. The absolute risk of all-cause death for someone aged 20-29 with RAIRD was similar to someone in the general population aged &gt;20 years older, someone aged 40-49 years with RAIRD similar to someone in the general population 20 years older, and someone aged 60-69 with RAIRD similar to someone in the general population aged &gt;10 years older. Conclusion  The excess risk of all-cause death during COVID-19 occurs at a younger age among people with RAIRD than among the general population, and particularly affects females. . We urgently need to quantify how much risk is due to COVID-19 infection and how much due to disruption to healthcare services to inform better guidance about shielding, access to healthcare and vaccine priorities for people with rare diseases. Disclosure  M. Rutter: None. P.C. Lanyon: None. E. Peach: None. M.J. Grainge: None. R.B. Hubbard: None. J. Aston: None. M. Bythell: None. S. Stevens: None. F.A. Pearce: None.

scholarly journals One-Year Mortality Rates Following Fracture of the Femoral Neck Treated With Hip Arthroplasty in an Aging Saudi Population: A Trauma Center Experience

2020 ◽  
Vol 11 ◽  
pp. 215145932092247 ◽  
Author(s):  
Omar A. Al-Mohrej ◽  
Fawaz N. Alshaalan ◽  
Sahar S. Aldakhil ◽  
Wael A. Rahman
Keyword(s):  
Mortality Rate ◽  
Total Hip Arthroplasty ◽  
Femoral Neck ◽  
Hip Arthroplasty ◽  
Mortality Rates ◽  
Morbidity And Mortality ◽  
Secondary Outcome ◽  
High Morbidity ◽  
Old Patients ◽  
Total Hip

Introduction: Femoral neck fracture is a common problem in elderly patients, and it is managed with either total hip arthroplasty or hemiarthroplasty with very good outcomes. However, the reported 1-year mortality rate is as high as 33%. Material and Methods: This study was a retrospective cohort study. The electronic patient records were searched for all physiologically old patients with displaced femoral neck fractures that were managed with either hemiarthroplasty or total hip arthroplasty. The primary aim of this study was to estimate morbidity and mortality rates at 30 days and 1 year. The secondary outcome was to determine major complications and factors influencing mortality. Results: From January 2017 to December 2018, a total of 99 patients were included in the study. Of those, 57 were female patients. The mortality rate was 15.2%. The significant predictors of death included the age at the time of surgery, readmission within 30 days of initial admission, acute renal impairment, and the need for preoperative medical intervention. Patients treated with total hip arthroplasty had lower mortality rates than those treated with hemiarthroplasty ( P = .017). Discussion: To the best of our knowledge, this is the first study conducted in Saudi Arabia to report detailed perioperative-related complications and outcomes following neck of femur fractures. The results of our study confirm the persistently high morbidity and mortality associated with this patient group. Conclusion: Efforts should be aimed at optimizing preoperative medical management, which is vital to ensure early identification of medically unfit patients.

Craniotomy for meningioma in the United States between 1988 and 2000: decreasing rate of mortality and the effect of provider caseload

2005 ◽  
Vol 102 (6) ◽  
pp. 977-986 ◽  
Author(s):  
William T. Curry ◽  
Michael W. McDermott ◽  
Bob S. Carter ◽  
Fred G. Barker
Keyword(s):  
Mortality Rate ◽  
Hospital Discharge ◽  
High Volume ◽  
Mortality Rates ◽  
Content Type ◽  
Relative Mortality ◽  
Discharge Disposition ◽  
The Us ◽  
Meningioma Surgery ◽  
Fine Print

Object. The goal of this study was to determine the risk of adverse outcomes after contemporary surgical treatment of meningiomas in the US and trends in patient outcomes and patterns of care. Methods. The authors performed a retrospective cohort study by using the Nationwide Inpatient Sample covering the period of 1988 to 2000. Multivariate regression models with disposition end points of death and hospital discharge were used to test patient, surgeon, and hospital characteristics, including volume of care, as outcome predictors. Multivariate analyses revealed that larger-volume centers had lower mortality rates for patients who underwent craniotomy for meningioma (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.59–0.93, p = 0.01). Adverse discharge disposition was also less likely at high-volume hospitals (OR 0.71, 95% CI 0.62–0.80, p < 0.001). With respect to the surgeon caseload, there was a trend toward a lower rate of mortality after surgery when higher-caseload providers were involved, and a significantly less frequent adverse discharge disposition (OR 0.71, 95% CI 0.62–0.80, p <, 0.001). The annual meningioma caseload in the US increased 83% between 1988 and 2000, from 3900 patients/year to 7200 patients/year. In-hospital mortality rates decreased 61%, from 4.5% in 1988 to 1.8% in 2000. Reductions in the mortality rates were largest at high-volume centers (a 72% reduction in the relative mortality rate at largest-volume-quintile centers, compared with a 6% increase in the relative mortality rate at lowest-volume-quintile centers). The number of US hospitals where craniotomies were performed for meningiomas increased slightly. Fewer centers hosted one meningioma resection annually, whereas the largest centers had disproportionate increases in their caseloads, indicating a modest centralization of meningioma surgery in the US during this interval. Conclusions. The mortality and adverse hospital discharge disposition rates were lower when meningioma surgery was performed by high-volume providers. The annual US caseload increased, whereas the mortality rates decreased, especially at high-volume centers.

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