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Association of Positive Fluid Balance at Discharge After Sepsis Management With 30-Day Readmission.
Yoo, MS, Zhu, S, Lu, Y, Greene, JD, Hammer, HL, Iberti, CT, Nemazie, S, Ananias, MP, McCarthy, CM, O'Malley, RM, et al
JAMA network open. 2021;(6):e216105
Abstract
IMPORTANCE Although early fluid administration has been shown to lower sepsis mortality, positive fluid balance has been associated with adverse outcomes. Little is known about associations in non-intensive care unit settings, with growing concern about readmission from excess fluid accumulation in patients with sepsis. OBJECTIVE To evaluate whether positive fluid balance among non-critically ill patients with sepsis was associated with increased readmission risk, including readmission for heart failure. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study was conducted between January 1, 2012, and December 31, 2017, among 57 032 non-critically ill adults hospitalized for sepsis at 21 hospitals across Northern California. Kaiser Permanente Northern California is an integrated health care system with a community-based population of more than 4.4 million members. Statistical analysis was performed from January 1 to December 31, 2019. EXPOSURES Intake and output net fluid balance (I/O) measured daily and cumulatively at discharge (positive vs negative). MAIN OUTCOMES AND MEASURES The primary outcome was 30-day readmission. The secondary outcomes were readmission stratified by category and mortality after living discharge. RESULTS The cohort included 57 032 patients who were hospitalized for sepsis (28 779 women [50.5%]; mean [SD] age, 73.7 [15.5] years). Compared with patients with positive I/O (40 940 [71.8%]), those with negative I/O (16 092 [28.2%]) were older, with increased comorbidity, acute illness severity, preexisting heart failure or chronic kidney disease, diuretic use, and decreased fluid administration volume. During 30-day follow-up, 8719 patients (15.3%) were readmitted and 3639 patients (6.4%) died. There was no difference in readmission between patients with positive vs negative I/O (HR, 1.00; 95% CI, 0.95-1.05). No association was detected between readmission and I/O using continuous, splined, and quadratic function transformations. Positive I/O was associated with decreased heart failure-related readmission (HR, 0.80 [95% CI, 0.71-0.91]) and increased 30-day mortality (HR, 1.23 [95% CI, 1.15-1.31]). CONCLUSIONS AND RELEVANCE In this large observational study of non-critically ill patients hospitalized with sepsis, there was no association between positive fluid balance at the time of discharge and readmission. However, these findings may have been limited by variable recording and documentation of fluid intake and output; additional studies are needed to examine the association of fluid status with outcomes in patients with sepsis to reduce readmission risk.
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Utility of neutrophil-to-lymphocyte ratio to identify long-term survivors among HCC patients treated with sorafenib.
Casadei-Gardini, A, Dadduzio, V, Rovesti, G, Cabibbo, G, Vukotic, R, Rizzato, MD, Orsi, G, Rossi, M, Guarneri, V, Lonardi, S, et al
Medicine. 2020;(22):e19958
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Abstract
Sorafenib is the first multikinase inhibitor demonstrating a survival benefit for patients suffering from advanced hepatocellular carcinoma (HCC). However, 1 issue remains open: what is the factor able to predict which patients will be long survivors?In the present study, we harnessed the potential of conditional survival, aiming at estimating the probability that a patient receiving sorafenib survives for more than 3 years.The present multicentric study was conducted on a cohort of 438 HCC patients. The primary end point was conditional overall survival. Kaplan-Meier survival analysis was used to calculate conditional overall survival probabilities at 3 years.The 3-year conditional survival of patients without disease progression highlights that NLR and ECOG are the factors that most accurately predict the probability of long survival. The 3-year conditional survival of patients with disease progression showed a medium effect size for HCV status, alpha-fetoprotein and NLR at all time-points. Macro-vascular portal vein invasion, extra hepatic disease, and BCLC we have a large effect size at 6 months and a medium effect size at 12 and 24 months.Our findings support the use of baseline NLR for the identification of patients with a higher probability of long-survival. NLR should be used as a stratification factor in the forthcoming clinical trials on the drugs for the advanced HCC now in pipeline.
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Determinants of long-term outcome in ICU survivors: results from the FROG-ICU study.
Gayat, E, Cariou, A, Deye, N, Vieillard-Baron, A, Jaber, S, Damoisel, C, Lu, Q, Monnet, X, Rennuit, I, Azoulay, E, et al
Critical care (London, England). 2018;(1):8
Abstract
BACKGROUND Intensive care unit (ICU) survivors have reduced long-term survival compared to the general population. Identifying parameters at ICU discharge that are associated with poor long-term outcomes may prove useful in targeting an at-risk population. The main objective of the study was to identify clinical and biological determinants of death in the year following ICU discharge. METHODS FROG-ICU was a prospective, observational, multicenter cohort study of ICU survivors followed 1 year after discharge, including 21 medical, surgical or mixed ICUs in France and Belgium. All consecutive patients admitted to intensive care with a requirement for invasive mechanical ventilation and/or vasoactive drug support for more than 24 h following ICU admission and discharged from ICU were included. The main outcome measure was all-cause mortality at 1 year after ICU discharge. Clinical and biological parameters on ICU discharge were measured, including the circulating cardiovascular biomarkers N-terminal pro-B type natriuretic peptide, high-sensitive troponin I, bioactive-adrenomedullin and soluble-ST2. Socioeconomic status was assessed using a validated deprivation index (FDep). RESULTS Of 1570 patients discharged alive from the ICU, 333 (21%) died over the following year. Multivariable analysis identified age, comorbidity, red blood cell transfusion, ICU length of stay and abnormalities in common clinical factors at the time of ICU discharge (low systolic blood pressure, temperature, total protein, platelet and white cell count) as independent factors associated with 1-year mortality. Elevated biomarkers of cardiac and vascular failure independently associated with 1-year death when they are added to multivariable model, with an almost 3-fold increase in the risk of death when combined (adjusted odds ratio 2.84 (95% confidence interval 1.73-4.65), p < 0.001). CONCLUSIONS The FROG-ICU study identified, at the time of ICU discharge, potentially actionable clinical and biological factors associated with poor long-term outcome after ICU discharge. Those factors may guide discharge planning and directed interventions. TRIAL REGISTRATION ClinicalTrials.gov NCT01367093 . Registered on 6 June 2011.
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Determinants of Health-Related Quality of Life After ICU: Importance of Patient Demographics, Previous Comorbidity, and Severity of Illness.
Griffith, DM, Salisbury, LG, Lee, RJ, Lone, N, Merriweather, JL, Walsh, TS, ,
Critical care medicine. 2018;(4):594-601
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Abstract
OBJECTIVES ICU survivors frequently report reduced health-related quality of life, but the relative importance of preillness versus acute illness factors in survivor populations is not well understood. We aimed to explore health-related quality of life trajectories over 12 months following ICU discharge, patterns of improvement, or deterioration over this period, and the relative importance of demographics (age, gender, social deprivation), preexisting health (Functional Comorbidity Index), and acute illness severity (Acute Physiology and Chronic Health Evaluation II score, ventilation days) as determinants of health-related quality of life and relevant patient-reported symptoms during the year following ICU discharge. DESIGN Nested cohort study within a previously published randomized controlled trial. SETTING Two ICUs in Edinburgh, Scotland. PATIENTS Adult ICU survivors (n = 240) who required more than 48 hours of mechanical ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We prospectively collected data for age, gender, social deprivation (Scottish index of multiple deprivation), preexisting comorbidity (Functional Comorbidity Index), Acute Physiology and Chronic Health Evaluation II score, and days of mechanical ventilation. Health-related quality of life (Medical Outcomes Study Short Form version 2 Physical Component Score and Mental Component Score) and patient-reported symptoms (appetite, fatigue, pain, joint stiffness, and breathlessness) were measured at 3, 6, and 12 months. Mean Physical Component Score and Mental Component Score were reduced at all time points with minimal change between 3 and 12 months. In multivariable analysis, increasing pre-ICU comorbidity count was strongly associated with lower health-related quality of life (Physical Component Score β = -1.56 [-2.44 to -0.68]; p = 0.001; Mental Component Score β = -1.45 [-2.37 to -0.53]; p = 0.002) and more severe self-reported symptoms. In contrast, Acute Physiology and Chronic Health Evaluation II score and mechanical ventilation days were not associated with health-related quality of life. Older age (β = 0.33 [0.19-0.47]; p < 0.001) and lower social deprivation (β = 1.38 [0.03-2.74]; p = 0.045) were associated with better Mental Component Score health-related quality of life. CONCLUSIONS Preexisting comorbidity counts, but not severity of ICU illness, are strongly associated with health-related quality of life and physical symptoms in the year following critical illness.
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Prognostic factors associated with 15-year mortality in patients with hospitalized systolic HF: Results of the observational community-based EPICAL cohort study.
Agrinier, N, Thilly, N, Briançon, S, Juillière, Y, Mertes, PM, Villemot, JP, Alla, F, Zannad, F, ,
International journal of cardiology. 2017;:940-947
Abstract
AIMS: Little data on very long-term survival and associated prognostic factors in heart failure (HF) are available. The aim was to describe 15-year survival and to identify the baseline prognostic factors associated with mortality in a community-based sample of patients hospitalized for systolic HF. METHODS Vital status was collected 15years after inclusion of 352 patients hospitalized for systolic HF born in France from the prospective cohort EPICAL. The prognostic value of baseline socioeconomic, clinical and biological characteristics on 15-year mortality was assessed using Cox models. RESULTS The mean (±SD) age was 63.9 (±10.8)years, 76% of the patients were male, median left ventricular ejection fraction (LVEF) was 23% IR [18-27]. Overall, the mean (±SD) follow-up was 1826 (±111)days. A total of 290 (82.4%) deaths and 22 heart transplantations occurred during the follow-up. The 15-year survival rate was 13.2% (95% CI [9.0-16.3]), i.e. 4.7 times lower than the one observed in the general population. Baseline characteristics associated with 15-year mortality were: age older than 65years (HR=1.48, CI 95% [1.15-1.90]), diabetes mellitus (1.31 [1.00-1.72]), chronic kidney disease (1.73 [1.23-2.43]), serious comorbidity (1.29 [1.02-1.64]), time from first HF diagnosis exceeding 1year at inclusion (1.68 [1.26-2.24]), HF hospitalization during the previous 12months (1.36 [1.04-1.78]), heart rate higher than 110 beats per minute (1.87 [1.26-2.76]), LVEF % (0.88 per quartile increase [0.80-1.98]), and serum sodium below 130mmol/L (3.14 [1.76-5.61]. CONCLUSIONS Only 13% of patients hospitalized for HF survived at 15years. The usual mid-term prognostic factors are also predictive of very long-term survival.
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Diet and exercise in uterine cancer survivors (DEUS pilot) - piloting a healthy eating and physical activity program: study protocol for a randomized controlled trial.
Koutoukidis, DA, Beeken, RJ, Manchanda, R, Burnell, M, Knobf, MT, Lanceley, A
Trials. 2016;(1):130
Abstract
BACKGROUND Endometrial cancer survivors comprise a high-risk group for obesity-related comorbidities. Healthy eating and physical activity can lead to better health and well-being, but this population may experience difficulties adopting healthy lifestyle practices. Personalised behaviour change programmes that are feasible, acceptable and cost-effective are needed. The aim of this trial is to pilot a manualised programme about healthy eating and physical activity. METHODS/DESIGN This is a phase II, individually randomized, parallel, controlled, two-site, pilot clinical trial. Adult endometrial cancer survivors (n = 64) who have been diagnosed with endometrial cancer within the previous 3 years and are not on active treatment will be invited to participate. Participants will be assigned in a 1:1 ratio through minimisation to either an 8-week, group-based, behaviour-change programme with weekly 90-min sessions about healthy eating and physical activity or usual care. The intervention will focus on self-monitoring, goal setting and self-rewards. Follow-up assessments will be conducted at 8 and 24 weeks from the baseline assessment. Primary feasibility outcomes will include rates of recruitment, adherence, and retention. DISCUSSION The study results will inform the development of a definitive randomised controlled trial to test if the programme can improve the health and quality of life of this population. It will also provide guidance on costing the intervention and the health care resource use in this population. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02433080, 20 April 2015.
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Diagnostic utility of the impact of event scale-revised in two samples of survivors of war.
Morina, N, Ehring, T, Priebe, S
PloS one. 2013;(12):e83916
Abstract
The study aimed at examining the diagnostic utility of the Impact of Event Scale-Revised (IES-R) as a screening tool for post-traumatic stress disorder (PTSD) in survivors of war. The IES-R was completed by two independent samples that had survived the war in the Balkans: a sample of randomly selected people who had stayed in the area of former conflict (n = 3,313) and a sample of refugees to Western European countries (n = 854). PTSD was diagnosed using the MINI International Neuropsychiatric Interview. Prevalence of PTSD was 20.1% in the Balkan sample and 33.1% in the refugee sample. Results revealed that when considering a minimum value of specificity of 0.80, the optimally sensitive cut-off score for screening for PTSD in the Balkan sample was 34. In both the Balkan sample and the refugee sample, this cut-off score provided good values on sensitivity (0.86 and 0.89, respectively) and overall efficiency (0.81 and 0.79, respectively). Further, the kappa coefficients for sensitivity for the cut-off of 34 were 0.80 in both samples. Findings of this study support the clinical utility of the IES-R as a screening tool for PTSD in large-scale research studies and intervention studies if structured diagnostic interviews are regarded as too labor-intensive and too costly.