Predictors of septic shock in initially stable patients with pyogenic liver abscess.

OBJECTIVES: The incidence of pyogenic liver abscess (PLA), a life-threatening condition, is increasing worldwide. This study was designed to evaluate clinical features and outcomes in initially stable patients with PLA and to determine the predictors of septic shock. METHODS: The medical records of all adult patients who were hemodynamically stable and diagnosed with PLA in the emergency department from January 2010 to December 2014, inclusive, were reviewed. The primary outcome was septic shock. RESULTS: A review of medical records identified 453 patients (66.7% male), of mean age 61.4 years, diagnosed with PLA. Of these patients, 73 (16.1%) had septic shock and 10 (2.2%) died in-hospital. Of the 73 patients with septic shock, nine (12.3%) died in-hospital. The most common symptom was fever (79.5%), and the most common infectious agent was Klebsiella pneumoniae. Septic shock was significantly associated with age ≥60 years [odds ratio (OR): 2.99, 95% confidence interval (CI): 1.38-6.48], malignancy (OR: 2.11, 95% CI: 1.08-4.09), systolic blood pressure <100 mmHg (OR: 3.63, 95% CI: 1.43-9.21), respiratory rate ≥24/min (OR: 3.15, 95% CI: 1.20-8.28) and lactate concentration ≥2 mmol/L (OR: 4.92, 95% CI: 2.51-9.64). Septic shock also tended to be associated with procalcitonin concentration, but this was not statistically significant (OR: 3.42, 95% CI: 0.96-12.18). CONCLUSIONS: Septic shock was frequent in initially stable patients with PLA and was associated with older age, malignancy, low blood pressure, tachypnea and elevated lactate concentration.

Misdiagnosis of Spontaneous Intracranial Hypotension as a Risk Factor for Subdural Hematoma.

OBJECTIVE: This study aimed to evaluate the association between misdiagnosis of spontaneous intracranial hypotension (SIH) and subdural hematoma development. BACKGROUND: Although SIH is more prevalent than expected and causes potentially life-threatening complications including subdural hematoma (SDH), the association between misdiagnosis of SIH and SDH development is not yet evaluated. METHODS: Retrospective observational study was conducted between January 1, 2005, and December 31, 2014. Adult patients with spontaneous intracranial hypotension (age ≥ 18 years) were enrolled. RESULTS: Of the 128 patients with SIH, 111 (86.7%) were in no SDH group and 17 (13.3%) were in SDH group. Their clinical presentation did not show significant different between the two groups, except age, the days from symptom onset to correct diagnosis, and the number of misdiagnoses. Age (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.07-1.23) and the number of times SIH was misdiagnosed (OR, 1.82; 95% CI, 1.03-3.21) were independent risk factors for the development of SDH in SIH patients by multivariate logistic analysis. The clinical outcomes, including length of hospital stay and revisit rate, were similar in the two groups. CONCLUSIONS: The number of times SIH was misdiagnosed was associated with the later development of SDH perhaps because of delay in correct diagnosis of SIH. Clinicians would prevent the later complication of SDH in SIH patients by increasing the awareness and a high index of suspicion of SIH.

Predictive performance of the quick Sequential Organ Failure Assessment score as a screening tool for sepsis, mortality, and intensive care unit admission in patients with febrile neutropenia.

PURPOSE: In Sepsis-3, the quick Sequential Organ Failure Assessment (qSOFA) score was developed as criteria to use for recognizing patients who may have poor outcomes. This study was performed to evaluate the predictive performance of the qSOFA score as a screening tool for sepsis, mortality, and intensive care unit (ICU) admission in patients with febrile neutropenia (FN). We also tried to compare its performance with that of the systemic inflammatory response syndrome (SIRS) criteria and Multinational Association of Supportive Care in Cancer (MASCC) score for FN. METHODS: We used a prospectively collected adult FN data registry. The qSOFA and SIRS scores were calculated retrospectively using the preexisting data. The primary outcome was the development of sepsis. The secondary outcomes were ICU admission and 28-day mortality. RESULTS: Of the 615 patients, 100 developed sepsis, 20 died, and 38 were admitted to ICUs. In multivariate analysis, qSOFA was an independent factor predicting sepsis and ICU admission. However, compared to the MASCC score, the area under the receiver operating curve of qSOFA was lower. qSOFA showed a low sensitivity (0.14, 0.2, and 0.23) but high specificity (0.98, 0.97, and 0.97) in predicting sepsis, 28-day mortality, and ICU admission. CONCLUSIONS: Performance of the qSOFA score was inferior to that of the MASCC score. The preexisting risk stratification tool is more useful for predicting outcomes in patients with FN.

Contrast-induced nephropathy in patients with active cancer undergoing contrast-enhanced computed tomography.

PURPOSE: This study was performed to measure the incidence and identify potential predictors of contrast-induced nephropathy (CIN) in cancer patients without chronic kidney disease and with normal or near-normal baseline serum creatinine measures who underwent contrast-enhanced computed tomography (CECT). Severity of CIN was reported based on the RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal disease) classification of acute kidney injury. METHODS: A retrospective analysis was performed on 820 cancer patients who presented at our emergency department from October 2014 to March 2015. CIN was defined as an increase in creatinine concentration of ≥0.5 mg/dL or ≥25 % above baseline that occurred 48 to 72 h after CECT. RESULTS: The incidence of CIN was 8.0%. Serial CT examination [odds ratio (OR) 4.09; 95% confidence interval (CI) 1.34-12.56], hypotension before the CT scan (OR 3.95; 95% CI 1.77-8.83), liver cirrhosis (OR 2.82; 95% CI 1.06-7.55), BUN/creatinine >20 (OR 2.54; 95% CI 1.44-4.46), and peritoneal carcinomatosis (OR 1.75; 95% CI 1.01-3.00) were independently associated with CIN. Of 66 CIN patients, 44 met any of the severity criteria of the RIFLE classification. Five of these patients died during hospitalization but only one death was related to renal failure. CONCLUSIONS: Even when the baseline serum creatinine is ≤1.5 mg/dL, a significant portion of cancer patients are still at risk of CIN. Consecutive CECT examinations, hypotension before CT, liver cirrhosis, dehydration, and peritoneal carcinomatosis seem to predispose patients to CIN.

A new prognostic model for chemotherapy-induced febrile neutropenia.

BACKGROUND: The objective of this study was to develop and validate a new prognostic model for febrile neutropenia (FN). METHODS: This study comprised 1001 episodes of FN: 718 for the derivation set and 283 for the validation set. Multivariate logistic regression analysis was performed with unfavorable outcome as the primary endpoint and bacteremia as the secondary endpoint. RESULTS: In the derivation set, risk factors for adverse outcomes comprised age ≥ 60 years (2 points), procalcitonin ≥ 0.5 ng/mL (5 points), ECOG performance score ≥ 2 (2 points), oral mucositis grade ≥ 3 (3 points), systolic blood pressure <90 mmHg (3 points), and respiratory rate ≥ 24 breaths/min (3 points). The model stratified patients into three severity classes, with adverse event rates of 6.0 % in class I (score ≤ 2), 27.3 % in class II (score 3-8), and 67.9 % in class III (score ≥ 9). Bacteremia was present in 1.1, 11.5, and 29.8 % of patients in class I, II, and III, respectively. The outcomes of the validation set were similar in each risk class. When the derivation and validation sets were integrated, unfavorable outcomes occurred in 5.9 % of the low-risk group classified by the new prognostic model and in 12.2 % classified by the Multinational Association for Supportive Care in Cancer (MASCC) risk index. CONCLUSIONS: With the new prognostic model, we can classify patients with FN into three classes of increasing adverse outcomes and bacteremia. Early discharge would be possible for class I patients, short-term observation could safely manage class II patients, and inpatient admission is warranted for class III patients.

Impact of time to antibiotics on outcomes of chemotherapy-induced febrile neutropenia.

PURPOSE: The aim of this study was to determine the relationship between the time to antibiotic administration and patients' outcomes of febrile neutropenia (FN). We also investigated the relationship between the time to antibiotics and mortality rates in a subgroup of patients with bacteremia or severe sepsis or septic shock. METHODS: From the Neutropenic Fever Registry, we analyzed 1001 consecutive FN episodes diagnosed from November 1, 2011, to August 31, 2014. Timing cutoffs for antibiotics included the following: ≤1 vs. >1 h, ≤2 vs. >2 h, ≤3 vs. >3 h, and ≤4 vs. >4 h. Multivariate logistic regression was used to adjust for potential confounders in the association between timing intervals and outcomes of FN episodes. RESULTS: The median length of time from triage to antibiotics was 140 min (interquartile range, 110-180 min). At each time cutoff, the time from triage to antibiotic administration was not significantly associated with FN outcomes after adjusting for potential confounders. Antibiotic timing was not significantly associated with complication rates in overall FN episodes. We failed to find a significant relationship between antibiotic timing and mortality in FN episodes with severe sepsis or septic shock or with bacteremia. Procalcitonin concentration and the Multinational Association for Supportive Care in Cancer (MASCC) risk index score were found to be more crucial determinants of outcomes in patients with FN. CONCLUSIONS: The time to antibiotic administration is not a major factor in FN outcomes.

Blatchford score is a useful tool for predicting the need for intervention in cancer patients with upper gastrointestinal bleeding.

BACKGROUND AND AIM: The Blatchford score is based on clinical and laboratory variables to predict the need for clinical interventions in upper gastrointestinal bleeding (UGIB). The primary object was to evaluate the Blatchford score with clinical and full Rockall scores in patients with active cancer presenting to the emergency department with UGIB. The secondary object was to assess the accuracy of the Blatchford score at different source of UGIB; cancer bleeding versus non-malignant lesions. METHODS: We reviewed and extracted data from electronic medical record on patients with active cancer presenting to the emergency department from January 2009 to December 2011. Clinical interventions included blood transfusion, therapeutic endoscopy, angiographic intervention, and surgery. RESULTS: Of the 225 patients included, 197 (87.6%) received interventions. Comparing the area under receiver-operator curves, the Blatchford score (0.86, 95% confidence interval [CI] 0.77-0.95) was superior to clinical Rockall (0.67, 95% CI 0.55-0.79) and full Rockall score (0.72, 95% CI 0.61-0.83) in predicting interventions. When the score of 2 or less is counted as negative, sensitivity of 0.99 and specificity of 0.54 were calculated. When the patients were separated according to the source of UGIB, sensitivity and specificity were not changed. CONCLUSIONS: The Blatchford score outperformed both Rockall scoring system in predicting intervention in patients with active cancer. The source of bleeding was not important factor in the score performance. The Blatchford score has a very good sensitivity. However, suboptimal specificity limits its role as sole means of decision making in cancer patient with UGIB.

Validation of the clinical prediction rule for recurrent venous thromboembolism in cancer patients: the Ottawa score.

PURPOSE: Recently, a clinical prediction rule for recurrent venous thromboembolism (VTE) in cancer patients, named Ottawa score, was derived to individualize treatments with different intensities. It is composed of four variables including sex, primary tumor site, tumor stage, and prior history of VTE. The objective of this study was to validate the Ottawa score in an independent patient population in a tertiary hospital in Korea. METHODS: Medical records of consecutive adult patients (>18 years) with active malignancy and newly diagnosed VTE from January 1, 2006 to December 31, 2010 were analyzed. Using the same definition of predictor variables in the original derivation study, patients were divided into low (score ≤ 0) and high (score ≥ 1) risk groups for recurrent VTE, and their actual recurrence rate were analyzed. RESULTS: Of the 546 patients with newly diagnosed VTE, 99 (18.1 %) had recurrent VTE during the follow-up period. In the low-risk group, 34 (13.2 %) had recurrence, compared to 65 (22.4 %) in the high-risk group. Ottawa score's performance showed 66 % sensitivity, 50 % specificity, 22 % positive predictive value, and 87 % negative predictive value in our validation cohort. CONCLUSION: We were not able to accurately ascertain the relevance of the Ottawa score in our validation cohort. Future validation studies, including a more diverse patient population with different cancer predominance, are warranted.

Adding procalcitonin to the MASCC risk-index score could improve risk stratification of patients with febrile neutropenia.

PURPOSE: Infectious complication could be life-threatening in patients with chemotherapy-induced febrile neutropenia (FN). The Multinational Association of Supportive Care in Cancer (MASCC) risk-index score is used to predict the complications of these patients, and it has been focused on identifying low-risk patients who may be candidates for outpatient management. In this study, we evaluated procalcitonin (PCT) and the MASCC score in predicting bacteremia and septic shock in patients with FN. METHODS: From November 2010 to October 2011, 355 patients with FN were prospectively enrolled. Clinical and laboratory findings, including procalcitonin, and the MASCC score were analyzed and correlated with the infectious complications of FN. RESULTS: Of the 355 patients, 35 (9.9 %) had bacteremia, and 25 (7.0 %) developed septic shock. PCT ≥ 0.5 ng/mL (OR 3.96, 95 % CI 1.51-10.40), platelet count <100 × 10(3)/mm(3) (OR 2.50, 95 % CI 1.10-5.66), and MASCC score <21 (OR 2.45, 95 % CI 1.03-5.85) were independently predictive of bacteremia, and PCT ≥ 1.5 ng/mL (OR 29.78, 95 % CI 9.10-97.39) and MASCC score <21 (OR 9.46, 95 % CI 3.23-27.72) were independent factors of septic shock. In 306 patients with low-risk FN classified by the MASCC score, 52 had PCT ≥ 0.5 ng/mL and 31 had PCT ≥ 1.5 ng/mL. Of the 52 patients with PCT ≥ 0.5 ng/mL, 12 (23.1 %) had bacteremia, and of the 31 patients with PCT ≥ 1.5 ng/mL, 7 (22.6 %) developed septic shock. CONCLUSION: Implicating PCT as a routine use in clinical practice along with the MASCC score could improve risk stratification of patients with FN.

Malignant biliary obstructions: can we predict immediate postprocedural cholangitis after percutaneous biliary drainage?

PURPOSE: Percutaneous transhepatic biliary drainage (PTBD) is performed for the palliation of malignant biliary obstructions. The purpose of this study was to identify factors related to the occurrence of immediate cholangitis as a complication after PTBD METHODS: We retrospectively assessed 409 apparently stable patients with malignant biliary obstruction who underwent PTBD between January 2008 and December 2010. New onset cholangitis was defined as fever (>38 °C) that arose within 24 h after the intervention. Variables significantly associated with the occurrence of immediate cholangitis were selected and their odds ratio and 95 % confidence interval were calculated using logistic regression analysis. RESULTS: There were 106 (25.9 %) cases of immediate cholangitis following PTBD, and among those 106 cases, 45 (42.5 %) had sepsis. In multivariate analysis, history of cholangitis (OR 4.7, 95 % CI 2.45-9.18), biliary drainage within 6 months (OR 2.3, 95 % CI 1.26-4.15), CRP ≥ 5 mg/dL (OR 2.2, 95 % CI 1.23-4.03), and serum albumin <3 g/dL (OR 1.9, 95 % CI 1.023-3.40) were predictive of immediate cholangitis after PTBD for malignant biliary obstructions. CONCLUSIONS: Cholangitis is a common immediate complication after PTBD. Patients should always be given prophylactic antibiotics before the drainage procedures. The results of this study could highlight the patients who require closer follow-up in order to make PTBD a safer procedure.

Evaluating the performance of a turbulent wet scrubber for scrubbing particulate matter.

UNLABELLED: A turbulent wet scrubber was designed and developed to scrub particulate matter (PM) at micrometer and submicrometer levels from the effluent gas stream of an industrial coal furnace. Experiments were conducted to estimate the particle removal efficiency of the turbulent scrubber with different gas flow rates and liquid heads above the nozzle. Particles larger than 1 microm were removed very efficiently, at nearly 100%, depending upon the flow rate, the concentration of the dust-laden air stream, and the water level in the reservoir Particles smaller than 1 microm were also removed to a greater extent at higher gas flow rates and for greater liquid heads. Pressure-drop studies were also carried out to estimate the energy consumed by the scrubber for the entire range of particle sizes distributed in the carrier gas. A maximum pressure drop of 217 mm H2O was observed for a liquid head of 36 cm and a gas flow rate of 7 m3/min. The number of transfer units (NTU) analysis for the efficiencies achieved by the turbulent scrubber over the range of particles also reveals that the contacting power achieved by the scrubber is better except for smaller particles. The turbulent scrubber is more competent for scrubbing particulate matter, in particular PM2.5, than other higher energy or conventional scrubbers, and is comparable to other wet scrubbers of its kind for the amount of energy spent. IMPLICATIONS: The evaluation of the turbulent scrubber is done to add a novel scrubber in the list of wet scrubbers for industrial applications, yet simple in design, easy to operate, with better compactness, and with high efficiencies at lower energy consumption. Hence the turbulent scrubber can be used to combat particulate from industrial gaseous effluents and also has a scope to absorb gaseous pollutants if the gases are soluble in the medium used for particles capture.

Emergency department cancer unit and management of oncologic emergencies: experience in Asan Medical Center.

PURPOSE: With the increasing incidence of cancer patients, our institute set up an emergency department (ED) unit for cancer (cancer emergency room, CER). We intended to clarify the operating characteristics and administrative benefits of the CER. METHODS: The CER was opened in May 2009. Retrospective review of all patients managed in the CER from January 2010 to December 2010 was performed, and data of the patients during January 2008 to December 2008 were collected to compare the care before and after the introduction of the CER. RESULTS: A total of 5,502 cancer patients visited the CER during 2010; 88.8% had solid tumor and 11.2% had hematologic malignancies. Diagnosis was grouped into four categories: disease progression (55.5%), infection (22.8%), treatment-related complications (14.7%), and noncancer-related problems (7%). Common treatments included antibiotic administration (28.9%), pain control (22.9%), and drainage procedures (16.2%). Of the 5,502 patients, 52.7% were discharged, 0.2% died during the stay, home service was supplied to 0.6% for palliative care, and 4.5% were transferred to other hospitals including hospice care center. When compared with the year 2008, inpatient unit admission decreased, cost of care in both ED and inpatient unit was reduced (all P values <0.05). However, length of stay in ED and inpatient unit was not different. CONCLUSION: ED unit for cancer has a valuable role in managing patients with cancers, not only progression of disease but also various toxicities related to its treatments.

Predictive factors of bacteraemia in low-risk patients with febrile neutropenia.

PURPOSE: The authors intended to determine the predictive factors of bacteraemia in low-risk febrile neutropenia (FN) classified by the Multinational Association for Supportive Care in Cancer Risk Index score. METHODS: FN episodes managed in an emergency department from June 2009 to May 2010 were included. Clinical and laboratory features including procalcitonin (PCT) and C reactive protein (CRP) were retrospectively analysed. RESULTS: Of the total 285 episodes, 243 (85.3%) were classified as low risk. In this group, 19 (7.8%) had bacteraemia. There was a significant difference (p<0.05) in age, respiration rate ≥24 (36.8% vs 7.6%), Eastern Cooperative Oncology Group performance status (PS) ≥2 (42.1% vs 11.6%), platelet counts (107.0±42.4 vs 131.8±73.7 ×10(3)/mm(3)), serum aspartate aminotransferase (42.3±30.7 vs 28.7±17.4 IU/litre) and blood urea nitrogen (19.6±9.8 vs 11.6± 8.6 mg/dl) between episodes with and without bacteraemia. PCT ≥0.5 ng/ml and CRP ≥10 mg/dl had higher rates of bacteraemia than PCT <0.5 ng/ml (28.2% vs 3.9%, p<0.001) and CRP <10 mg/dl (13.9% vs 5.3%, p=0.022) did. On multivariate analysis, PCT ≥0.5 ng/ml (OR 4.7, 95% CI 1.38 to 16.29), respiration rate ≥24 (OR 4.1, 95% CI 1.20 to 13.63) and Eastern Cooperative Oncology Group PS ≥2 (OR 3.2, 95% CI 1.02 to 10.10) were predictive of bacteraemia in the low-risk group. CONCLUSION: PCT, tachypnoea and PS were predictive of bacteraemia in the low-risk patients with FN. If the patient has high probability of bacteraemia, the patient could benefit from parenteral antibiotic treatment while awaiting the blood culture results.

Predictive factors of poor prognosis in cancer patients with chemotherapy-induced febrile neutropenia.

OBJECTIVES: We intended to determine the predictive factors of poor prognosis in cancer patients with chemotherapy-induced febrile neutropenia (FN). METHODS: From January 1, 2007 to December 31, 2008, 396 episodes of FN in 346 cancer patients were retrospectively analyzed. Clinical and laboratory findings and Multinational Association of Supportive Care in Cancer (MASCC) risk-index score were analyzed and correlated with outcome. RESULTS: Of the 396 episodes, 73 (18.4%) had serious medical complications including 15 (3.8%) deaths. There was significant difference between unfavorable and favorable outcomes in age, gender, hypotension, tachypnea, duration of fever ≤24 h before admission (44.4% vs. 61.3%), interval of ≤7 days since last chemotherapy (34.2% vs. 16.1%), and duration of neutropenia ≥4 days (34.2% vs. 15.8%; P < 0.05 each), as did C-reactive protein (CRP; 15.0 vs. 7.5 mg dL(-1)) and platelet count (66.4 × 10(3) vs. 123.7 × 10(3) mm(-3);P < 0.001 each). MASCC score was significantly lower in unfavorable outcomes than favorable outcomes (19.0 vs. 24.6, P < 0.001). However, prophylactic antibiotics, treatment with granulocyte colony-stimulating factor (G-CSF), and history of FN were not associated with outcome. On multivariate analysis, MASCC risk-index score (OR 23.2, 95% CI 10.48-51.37), tachypnea (OR 3.61, 95% CI 1.44-9.08), thrombocytopenia (OR 3.41, 95% CI 1.69-6.89), increased CRP (OR 3.23, 95% CI 1.62-6.45), and prolonged neutropenia (OR 2.52, 95% CI 1.21-5.25) were independent predictors of unfavorable outcomes. CONCLUSION: MASCC risk-index score <21, tachypnea, thrombocytopenia, increased CRP, and prolonged neutropenia may be strongly associated with poor outcomes in cancer patients with FN.

Effect of Prophylactic Amiodarone Infusion on the Recurrence of Ventricular Arrhythmias in Out-of-Hospital Cardiac Arrest Survivors: A Propensity-Matched Analysis.

Amiodarone is recommended for shock-refractory ventricular arrhythmia during resuscitation; however, it is unknown whether amiodarone is effective for preventing ventricular arrhythmia recurrence in out-of-hospital cardiac arrest (OHCA) survivors treated with targeted temperature management (TTM). We investigated the effectiveness of prophylactic amiodarone in preventing ventricular arrhythmia recurrence in OHCA survivors. Data of consecutive adult non-traumatic OHCA survivors treated with TTM between 2010 and 2016 were extracted from prospective cardiac arrest registries of four tertiary care hospitals. The prophylactic amiodarone group was matched in a 1:1 ratio by using propensity scores. The primary outcome was ventricular arrhythmia recurrence requiring defibrillation during TTM. Among 295 patients with an initially shockable rhythm and 149 patients with initially non-shockable-turned-shockable rhythm, 124 patients (27.9%) received prophylactic amiodarone infusion. The incidence of ventricular arrhythmia recurrence was 11.26% (50/444). Multivariate analysis showed prophylactic amiodarone therapy to be the independent factor associated with ventricular arrhythmia recurrence (odds ratio 1.95, 95% CI 1.04⁻3.65, p = 0.04), however, no such association was observed (odds ratio 1.32, 95% CI 0.57⁻3.04, p = 0.51) after propensity score matching. In this propensity-score-matched study, prophylactic amiodarone infusion had no effect on preventing ventricular arrhythmia recurrence in OHCA survivors with shockable cardiac arrest. Prophylactic amiodarone administration must be considered carefully.

[Clinical outcomes and predictive factors of spontaneous survival in patients with fulminant hepatitis A].

BACKGROUNDS/AIMS: The occurrence of acute hepatitis A is increasing and its progression to fulminant hepatic failure (FHF) is frequent. We investigated the frequency and clinical outcomes of fulminant hepatitis A and also analyzed the predictive factors of spontaneous survival. METHODS: A total of 568 patients presented with acute hepatitis A from January 2003 to June 2008, of which the 35 (6.2%) patients with FHF were divided into two groups: spontaneous survival and transplant/death. These two groups were compared according to various clinical features including the MELD score and King's College Hospital (KCH) criteria. RESULTS: The rate of FHF development increased over time among patients with acute hepatitis A: 0% in 2003, 3.4% in 2004, 3.2% in 2005, 6.0% in 2006, 7.7% in 2007, and 13.0% in 2008. Twenty patients (57.1%) showed spontaneous survival, 13 (37.1%) received liver transplantation, and 5 (14.3%) died during hospitalization. The two groups of spontaneous survival (N=20) and transplant/death (N=15) showed significant differences in prothrombin time at admission and at its worst value, albumin at its worst value, and hepatic encephalopathy grade at admission and at its worst value. The MELD score was lower in the spontaneous-survival group than in the transplant/death group (27.0+/-7.8 vs. 37.0+/-7.1, mean+/-SD; P=0.001). However, KCH criteria did not differ significantly between the two groups. On multivariate analysis, HEP grade was the only significant predictive factor, being negatively correlated with spontaneous survival (OR=0.068, P=0.025). CONCLUSIONS: FHF due to hepatitis A has increased in recent years, and in our cohort the HEP grade was closely associated with spontaneous survival.

Prediction model for mortality in cancer patients with pneumonia: comparison with CURB-65 and PSI.

INTRODUCTION AND OBJECTIVES: We aimed to develop a new prediction model of mortality in cancer patients with pneumonia and to compare its performance with CURB-65 and the Pneumonia Severity Index (PSI). METHODS: Active cancer patients who were diagnosed with pneumonia at the Emergency Department (ED) from 7/1/2014 to 12/31/2014 were consecutively included. Clinical data were collected through a medical chart review. The primary outcome was the 28-day mortality, and clinical factors were analyzed using logistic regression analysis. RESULTS: Among a total of 218 analyzed patients with a median age of 64.0 years (IQR, 56.8-71.0) and a male proportion of 72%, 42 (19.3%) died within 28 days of ED admission. By multivariate logistic regression analysis, an ECOG performance status (PS) 3 (OR: 8.54, 95% CI: 3.42-21.33) or 4 (OR: 13.17, 95% CI: 3.19-54.32), SpO2 <90% (OR: 3.06, 95% CI: 1.17-8.00), and elevated lactic acid levels (OR: 1.42, 95% CI: 1.12-1.81) were significantly associated with mortality. With these three variables, a new prediction model with total scores ranged from 0 to 6 was generated. The area under the curve of the new prediction model was 0.840, compared with 0.673 and 0.586 for CURB-65 and PSI, respectively. CONCLUSION: In cancer patients with pneumonia, a poor ECOG PS, SpO2 <90%, and lactic acid elevation are independent predictors of mortality. The new prediction model, comprising three predictors, performs better in predicting mortality in cancer patients than CURB-65 or PSI.

Prognostic Value of Treatment Setting in Patients With Cancer Having Pulmonary Embolism: Comparison With the Pulmonary Embolism Severity Index.

BACKGROUND: Active cancer is a poor prognostic factor for survival after pulmonary embolism (PE). This retrospective cohort study was performed to investigate how accurately the pulmonary embolism severity index (PESI) predicts 30-day mortality in patients with active cancer. Whether the treatment setting (palliative vs curative) could predict mortality in these patients was also investigated. METHODS: All consecutive patients with active cancer and PE who visited the emergency department of Asan Medical Center in January 2007 to June 2014 were identified. The covariates for predicting 30-day mortality were PESI classification, treatment setting (curative vs palliative), brain natriuretic peptide ≥ 150 ng/L, troponin I ≥ 0.10 ng/mL, right ventricular dysfunction, deep vein thrombosis, and anticoagulants used. Cox proportional hazards regression analysis was used to assess the association between treatment setting and 30-day mortality. RESULTS: The PESI classification and 30-day mortality did not associate significantly. Area under the receiver-operating curve of the PESI was 0.565 (95% confidence interval [CI]: 0.453-0.677). Palliative treatment setting associated with an increased risk of 30-day mortality, regardless of the PESI classification (adjusted hazard ratio: 3.72, 95% CI: 1.49-9.26). Treatment setting predicted mortality 30 days, 3 months, and 6 months after PE presentation better than PESI. CONCLUSION: The PESI did not accurately predict mortality in patients with active cancer. Treatment setting was the most important determinant of clinical outcome in these patients. When stratifying patients with active cancer and PE, palliative treatment setting should be considered as it is predictive of high mortality.

Clinically significant hemodynamic alterations after propacetamol injection in the emergency department: prevalence and risk factors.

Propacetamol, a water-soluble prodrug form of paracetamol, is hydrolyzed by esterase to generate paracetamol in the blood. Each gram of propacetamol is equal to 0.5 g of paracetamol. It has been reported to cause hypotension in critically ill patients with a fever. We aimed to investigate the hemodynamic effects of propacetamol for the control of fever in patients with diverse severities of illness who were managed in the emergency department (ED). We also aimed to identify clinical factors related to significant hemodynamic alterations in ED patients. This was a retrospective study of 1507 ED patients who received propacetamol. Significant hemodynamic alterations were defined as systolic blood pressure (SBP) <90 mmHg or diastolic blood pressure (DBP) <60 mmHg, or a drop in SBP >30 mmHg, which required treatments with a bolus of fluid or vasopressor administration. Postinfusion SBP and DBP were significantly lower than the preinfusion SBP and DBP. A clinically significant drop in BP occurred in 162 (10.7 %) patients, and interventions were necessary. Among the predictors assessed, congestive heart failure (OR 6.21, 95 % CI 2.67-14.45) and chills (OR 3.10, 95 % CI 2.04-4.70) were independent factors for a significant hemodynamic change. Administration of propacetamol can provoke a reduction in BP in ED patients. This reduction was clinically significant for 10 % of infusions. Clinicians should be aware of this potential deleterious effect, especially in patients with congestive heart failure or who experience chills prior to the administration of propacetamol.