Mitigation of Blood Load Impact in Patients with Subarachnoid Hemorrhage by Cisternal Lavage

<b><i>Object:</i></b> The initial amount of subarachnoid and ventricular blood is an important prognostic factor for outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). In this comparative study of an unselected aSAH-population, we assess the modifiability of these factors by implementation of blood clearance by cisternal lavage. <b><i>Methods:</i></b> All patients with aSAH treated in our department between October 2011 and October 2019 (8 years, <i>n</i> = 458) were included in our study. In the first 4-year period (BEFORE, <i>n</i> = 237), patients were treated according to international guidelines. In the second 4-year period (AFTER, <i>n</i> = 221), cisternal lavage methods were available and applied in 72 high-risk patients (32.5%). The cisternal and ventricular blood load was recorded by the Hijdra score. Multivariable regression models were used to assess the prognostic significance of risk factors, including blood load, in relation to common aSAH characteristics in both study groups. <b><i>Results:</i></b> Worse neurological outcomes (mRS &#x3e; 3) occurred in the BEFORE population with 41.45% versus 30.77% in the AFTER cohort, 6 months after aSAH (HR: 1.59, 95% CI 1.08–2.34, <i>p</i> = 0.01). Admission WFNS grade, comorbidities (Charlson Comorbidity Index), herniation signs, concomitant intracerebral hemorrhage, and the development of delayed cerebral infarction were strongly associated with poor outcome in both study groups. Intraventricular and cisternal blood load and, particularly, a cast fourth ventricle (Cast 4) represented strong prognosticators of poor neurological outcome in the BEFORE cohort. This effect was lost after implementation of cisternal lavage (AFTER cohort). <b><i>Conclusion:</i></b> Cisternal and ventricular blood load – in particular: a Cast 4 – represent important prognosticators in patients with aSAH. They are, however, amenable to modification by blood clearing therapies.

The CLL comorbidity index in a population-based cohort: a tool for clinical care and research

The chronic lymphocytic leukemia comorbidity index (CLL-CI) is an efficient, CLL-specific tool derived from the Cumulative Illness Rating Scale. The CLL-CI is based on the assessment of the organ systems found to be most strongly associated with event-free survival in CLL: vascular, upper gastrointestinal, and endocrine, at the time of initiation of CLL therapy. The CLL-CI categorizes patients into low, intermediate, and high risk groups. In the present study, we have employed the CLL-CI in a population-based cohort comprising 4 975 patients with CLL. We demonstrate that CLL-CI retains prognostic significance in this large cohort and is associated with overall survival and event-free survival from time of first therapy. Furthermore, CLL-CI associates with overall survival, event-free survival, and time to first treatment from diagnosis independently of the CLL International Prognostic Index. These findings support the use of the CLL-CI both in research and in clinical practice.

Simple Excel and ICD-10 based dataset calculator for the Charlson and Elixhauser comorbidity indices

Background The Charlson and Elixhauser Comorbidity Indices are the most widely used comorbidity assessment methods in medical research. Both methods are adapted for use with the International Classification of Diseases, which 10th revision (ICD-10) is used by over a hundred countries in the world. Available Charlson and Elixhauser Comorbidity Index calculating methods are limited to a few applications with command-line user interfaces, all requiring specific programming language skills. This study aims to use Microsoft Excel to develop a non-programming and ICD-10 based dataset calculator for Charlson and Elixhauser Comorbidity Index and to validate its results with R- and SAS-based methods. Methods The Excel-based dataset calculator was developed using the program’s formulae, ICD-10 coding algorithms, and different weights of the Charlson and Elixhauser Comorbidity Index. Real, population-wide, nine-year spanning, index hip fracture data from the Estonian Health Insurance Fund was used for validating the calculator. The Excel-based calculator’s output values and processing speed were compared to R- and SAS-based methods. Results A total of 11,491 hip fracture patients’ comorbidities were used for validating the Excel-based calculator. The Excel-based calculator’s results were consistent, revealing no discrepancies, with R- and SAS-based methods while comparing 192,690 and 353,265 output values of Charlson and Elixhauser Comorbidity Index, respectively. The Excel-based calculator’s processing speed was slower but differing only from a few seconds up to four minutes with datasets including 6250–200,000 patients. Conclusions This study proposes a novel, validated, and non-programming-based method for calculating Charlson and Elixhauser Comorbidity Index scores. As the comorbidity calculations can be conducted in Microsoft Excel’s simple graphical point-and-click interface, the new method lowers the threshold for calculating these two widely used indices. Trial registration retrospectively registered.

Metabolic syndrome predicts new damage in systemic lupus erythematosus patients: Data from the Almenara Lupus Cohort

Objectives This study aims to determine whether the MetS predicts damage accrual in SLE patients. Methods This longitudinal study was conducted in a cohort of consecutive SLE patients seen since 2012 at one single Peruvian institution. Patients had a baseline visit and then follow-up visits every 6 months. Patients with ≥ 2 visits were included. Evaluations included interview, medical records review, physical examination, and laboratory tests. Damage accrual was ascertained with the SLICC/ACR damage index (SDI) and disease activity with the SLEDAI-2K. Univariable and multivariable Cox-regression survival models were carried out to determine the risk of developing new damage. The multivariable model was adjusted for age at diagnosis; disease duration; socioeconomic status; SLEDAI; baseline SDI; the Charlson Comorbidity Index; daily dose; and time of exposure of prednisone (PDN), antimalarials, and immunosuppressive drugs. Results Two hundred and forty-nine patients were evaluated; 232 of them were women (93.2%). Their mean (SD) age at diagnosis was 35.8 (13.1) years; nearly all patients were Mestizo. Disease duration was 7.4 (6.6) years. The SLEDAI-2K was 5.2 (4.3) and the SDI, 0.9 (1.3). One hundred and eight patients (43.4%) had MetS at baseline. During follow-up, 116 (46.6%) patients accrued at least one new point in the SDI damage index. In multivariable analyses, the presence of MetS was a predictor of the development of new damage (HR: 1.54 (1.05–2.26); p < 0.029). Conclusions The presence of MetS predicts the development of new damage in SLE patients, despite other well-known risk factors for such occurrence.

Effect of Charlson Comorbidity Index and Treatment Strategy on Survival of Elderly Patients After Endoscopic Submucosal Dissection for Gastric Adenocarcinoma: A Multicenter Retrospective Study

Background: The optimal treatment strategy for elderly patients with early gastric adenocarcinoma (EGAC) after non-curative endoscopic submucosal dissection (ESD) remains unclear. The purpose of this research was to explore the effectiveness of additional treatments after ESD and the factors affecting survival in elderly patients (≥60 years of age) with EGAC.Methods: A total of 639 elderly patients (≥60 years) treated with ESD for EGAC from 2006 to 2018 were retrospectively reviewed. Positive lymphatic infiltration, submucosal infiltration, and positive/indeterminate vertical resection margins are considered high risk factors in histology. According to the risk of lymph node metastasis in patients with EAGC and the treatment strategies adopted after ESD, patients were divided into three groups: there were 484 patients in group A with low risk, 121 patients in group B with high risk, without additional treatment, and 36 patients in group C with high risk, with additional treatment. The 5- and 8-year survival rate, as well as the prognostic factors of survival rate after ESD was studied.Results: The median follow-up time was 38, 40, and 49 months, respectively. There were 3, 4, and 3 deaths related to gastric adenocarcinoma in groups A, B, and C, while deaths from other diseases were 20, 5, and 3, respectively. There were significant differences in overall survival rates between groups (94.3; 86.4; 81.2%, p = 0.110), but there was no significant difference in disease-specific survival rates (98.4; 92.7; 92.4%, p = 0.016). In the multivariate analysis, the Charlson Comorbidity Index (CCI) ≥ 2 was an independent risk factor for death after ESD (hazard ratio 2.39; 95% confidence interval 1.20–4.77; p = 0.014).Conclusions: The strategy of ESD with no subsequent additional treatment for EGAC may be a suitable option for elderly patients at high risk, especially for CCI ≥ 2.

Charlson Comorbidity Index: A Critical Review of Clinimetric Properties

The present critical review was conducted to evaluate the clinimetric properties of the Charlson Comorbidity Index (CCI), an assessment tool designed specifically to predict long-term mortality, with regard to its reliability, concurrent validity, sensitivity, incremental and predictive validity. The original version of the CCI has been adapted for use with different sources of data, ICD-9 and ICD-10 codes. The inter-rater reliability of the CCI was found to be excellent, with extremely high agreement between self-report and medical charts. The CCI has also been shown either to have concurrent validity with a number of other prognostic scales or to result in concordant predictions. Importantly, the clinimetric sensitivity of the CCI has been demonstrated in a variety of medical conditions, with stepwise increases in the CCI associated with stepwise increases in mortality. The CCI is also characterized by the clinimetric property of incremental validity, whereby adding the CCI to other measures increases the overall predictive accuracy. It has been shown to predict long-term mortality in different clinical populations, including medical, surgical, intensive care unit (ICU), trauma, and cancer patients. It may also predict in-hospital mortality, although in some instances, such as ICU or trauma patients, the CCI did not perform as well as other instruments designed specifically for that purpose. The CCI thus appears to be clinically useful not only to provide a valid assessment of the patient’s unique clinical situation, but also to demarcate major diagnostic and prognostic differences among subgroups of patients sharing the same medical diagnosis.

Temperature Profile and Adverse Outcomes After Discharge From the Intensive Care Unit

Background A predictive model that uses the rhythmicity of core body temperature (CBT) could be an easily accessible clinical tool to ultimately improve outcomes among critically ill patients. Objectives To assess the relation between the 24-hour CBT profile (CBT-24) before intensive care unit (ICU) discharge and clinical events in the step-down unit within 7 days of ICU discharge. Methods This retrospective cohort study in a tertiary ICU at a single center included adult patients requiring acute invasive ventilation for more than 48 hours and assessed major clinical adverse events (MCAEs) and rapid response system activations (RRSAs) within 7 days of ICU discharge (MCAE-7 and RRSA-7, respectively). Results The 291 enrolled patients had a median mechanical ventilation duration of 139 hours (IQR, 50-862 hours) and at admission had a median Acute Physiology and Chronic Health Evaluation II score of 22 (IQR, 7-42). At least 1 MCAE or RRSA occurred in 64% and 22% of patients, respectively. Independent predictors of an MCAE-7 were absence of CBT-24 rhythmicity (odds ratio, 1.78 [95% CI, 1.07-2.98]; P = .03), Sequential Organ Failure Assessment score at ICU discharge (1.10 [1.00-1.21]; P = .05), male sex (1.72 [1.04-2.86]; P = .04), age (1.02 [1.00-1.04]; P = .02), and Charlson Comorbidity Index (0.87 [0.76-0.99]; P = .03). Age (1.03 [1.01-1.05]; P = .006), sepsis at ICU admission (2.02 [1.13-3.63]; P = .02), and Charlson Comorbidity Index (1.18 [1.02-1.36]; P = .02) were independent predictors of an RRSA-7. Conclusions Use of CBT-24 rhythmicity can assist in stratifying a patient’s risk of subsequent deterioration during general care within 7 days of ICU discharge.

Neurometabolic Therapy in Patients with Encephalopathy Associated with COVID-19

The objective: to evaluate the effectiveness of neurometabolic therapy in patients with severe course of the new coronavirus infection of COVID-19 complicated by the development of encephalopathy.Subjects and Methods. A pilot prospective study was carried out with the participation of 61 patients with a severe course of COVID-19 complicated by encephalopathy. The patients were randomized into two groups: the study group (n = 34), the patients in which, in contrast to the control group (n = 27), received Cytoflavin in addition to the main therapy in a daily dose of up to 40 ml for 5 days. The dynamics of the general and neurological status was assessed on days 3‒4 and 6‒7 days of treatment using the NEWS (National Early Warning Score), Glasgow coma and ICDSC (Intensive Care Delirium Screening Checklist) scales. Additionally, the blood level of neuron-specific enolase (NSE) was investigated at baseline and on days 6‒7.Results. Patients in most cases were elderly or senile with a high comorbidity index (up to 4 points according to Charlson). The persistence of delirious symptoms correlated with their age and low SpO2 levels. In half of the cases (50.8%), the disease had an unfavorable outcome. In the study group, by the 6‒7th day of treatment, there was a significant positive dynamics of the general condition, assessed by the NEWS scale (p = 0.012), a tendency towards a faster recovery of the overall score on the Glasgow scale (p = 0.083), a tendency towards more rapid regression of delirious symptoms by ICDSC scale (p = 0.055) versus the comparison group.Conclusions. Given the high risk of an unfavorable outcome in patients with a severe course of COVID-19 complicated by the development of encephalopathy, the additional use of Cytoflavin is advisable since it contributes to the regression of the symptoms of encephalopathy and may have a positive effect on the course of the disease.

A single-centre, retrospective analysis of mortality over 80 months comparing paclitaxel-coated balloon versus standard balloon angioplasty in the treatment of dysfunctional arteriovenous access

Aim: Percutaneous transluminal angioplasty (PTA) is a standard treatment for arteriovenous fistula (AVF) stenosis to preserve haemodialysis vascular access, promoting improved dialysis adequacy and better outcomes for those dependent on renal replacement therapy. Drug coated balloons (DCB) may help reduce the rate of neointimal hyperplasia and recurrent stenosis, but their use in femoropopliteal angioplasty has been associated with increased mortality at 2 and 5 year follow-up. This study aims to address the long-term safety of PTA for AVF stenosis with clinical correlation to participant co-morbidity and mortality. Methods: All patients undergoing PTA for AVF stenosis at a single centre between 2013 and 2017 were identified and grouped according to the use of DCB versus standard balloon angioplasty. All data was anonymised and correlated to verify independent predictors of mortality. Results: 481 (400 standard balloon; 81 DCB) procedures were performed in 313 patients (250 standard balloon; 63 DCB). Follow-up at 80 months did not show any difference in mortality ( p = 0.546). Multivariate analysis identified time on dialysis ( p < 0.001), age ( p = 0.001) and Charlson comorbidity index ( p = 0.02) as independent predictors of mortality. Conclusions: In this study, mortality was not associated with the use of DCBs, but was related to established factors of dialysis longevity, age and comorbidity.