Analysis of factors associated with the prognosis of cirrhotic patients who were treated with tolvaptan for hepatic edema.

BACKGROUND AND AIM: The prognosis of cirrhotic patients with hepatic edema is poor. Although several short-term predictors of tolvaptan (novel diuretic agent) treatment for such patients have been reported, the factors related to long-term survival are still unclear. METHODS: Among 459 patients with hepatic edema enrolled in a retrospective, multicenter collaborative study, we analyzed 407 patients who received tolvaptan. RESULTS: Patients consisted of 266 men and 141 women, with the median age of 68 years (range, 28-93 years). The frequency of short-term responders to tolvaptan was 59.7% (243/407). In the Cox regression analysis, short-term response to tolvaptan, low average dosages of furosemide and spironolactone during tolvaptan treatment, Child-Pugh classification A and B, and absence of hepatocellular carcinoma were independent factors contributed to 1-year survival. The 1-year and long-term cumulative survival rates in short-term responders were significantly higher than those in non-responders (P = 0.011 and 0.010, respectively). Using a receiver operating characteristic curve analysis, the optimal cut-off values of average daily dosages of furosemide and spironolactone for predicting 1-year survival were 19 and 23 mg/day, respectively. The long-term cumulative survival rates in patients who received a mean dosage of spironolactone < 23 mg/day during tolvaptan treatment were significantly higher than those receiving a mean dosage of ≥ 23 mg/day (P = 0.001). CONCLUSIONS: The present study suggests that the short-term response to tolvaptan and low dosages of conventional diuretics during tolvaptan treatment might improve the 1-year and long-term survival rates in cirrhotic patients with hepatic edema.

Myocardial Edema and Prognosis in Amyloidosis.

BACKGROUND: Prognosis in light-chain (AL) and transthyretin (ATTR) amyloidosis is influenced by cardiac involvement. ATTR amyloidosis has better prognosis than AL amyloidosis despite more amyloid infiltration, suggesting additional mechanisms of damage in AL amyloidosis. OBJECTIVES: The aim of the study was to assess the presence and prognostic significance of myocardial edema in patients with amyloidosis. METHODS: The study recruited 286 patients: 100 with systemic AL amyloidosis, 163 with cardiac ATTR amyloidosis, 12 with suspected cardiac ATTR amyloidosis (grade 1 on 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid), 11 asymptomatic individuals with amyloidogenic TTR gene mutations, and 30 healthy volunteers. All subjects underwent cardiovascular magnetic resonance with T1 and T2 mapping and 16 underwent endomyocardial biopsy. RESULTS: Myocardial T2 was increased in amyloidosis with the degree of elevation being highest in untreated AL patients (untreated AL amyloidosis 56.6 ± 5.1 ms; treated AL amyloidosis 53.6 ± 3.9 ms; ATTR amyloidosis 54.2 ± 4.1 ms; each p < 0.01 compared with control subjects: 48.9 ± 2.0 ms). Left ventricular (LV) mass and extracellular volume fraction were higher in ATTR amyloidosis compared with AL amyloidosis while LV ejection fraction was lower (p < 0.001). Histological evidence of edema was present in 87.5% of biopsy samples ranging from 5% to 40% myocardial involvement. Using Cox regression models, myocardial T2 predicted death in AL amyloidosis (hazard ratio: 1.48; 95% confidence interval: 1.20 to 1.82) and remained significant after adjusting for extracellular volume fraction and N-terminal pro-B-type natriuretic peptide (hazard ratio: 1.32; 95% confidence interval: 1.05 to 1.67). CONCLUSIONS: Myocardial edema is present in cardiac amyloidosis by histology and cardiovascular magnetic resonance T2 mapping. T2 is higher in untreated AL amyloidosis compared with treated AL and ATTR amyloidosis, and is a predictor of prognosis in AL amyloidosis. This suggests mechanisms additional to amyloid infiltration contributing to mortality in amyloidosis.

Diuretics Combined With Compression in Resistant Limb Edema of Advanced Disease-A Case Series Report.

INTRODUCTION: The extremity edema of advanced disease is a common, multifactorial feature, which impairs patients' activities and quality of life. The most frequently chosen management is based on combined decongestive physiotherapy or pharmacotherapy (with diuretics or steroids). Subcutaneous lymphatic drainage in refractory edema may decrease the swelling, prevent spontaneous lymphorrhea, but also increase the risk of infection. Safe and effective conservative management in diuretics-resistant edemas is lacking. The objective of this prospective, observational study was to assess the effectiveness and tolerability of combined physiotherapeutic and diuretic therapy in edemas refractory to parenteral diuretics. METHODS: A group of 19 patients with advanced disease and severe bilateral leg edema resistant to parenteral diuretic therapy were treated for three days with a combination of multilayer short-stretch compression bandaging and furosemide in hypersaline intravenous infusion. RESULTS: A clinically meaningful decrease in mean limb volume (of 1.52 L; 20.6%; P < 0.0001)-strongly correlating with patients' weight loss (ρ = 0.71; P = 0.0001), with a lowering of the intensity of complaints-was achieved. The treatment was well tolerated, without decreasing the performance status in any patient. Stable levels of blood pressure, laboratory kidney profile (potassium, sodium, creatinine clearance), and serum albumin were observed. Maintenance of the achieved results with a good compliance was seen during an informal follow-up at the hospice. CONCLUSION: The combination of compression therapy with hypersaline diuretics could be considered as a valuable option for refractory cases of limb edema in advanced disease.

Decompressive hemicraniectomy for malignant middle cerebral artery infarction. Experience from the Western Province of Saudi Arabia.

OBJECTIVE: To describe our experience implementing decompressive hemicraniectomy (DH) for eligible patients with malignant middle cerebral artery (MCA) infarcts. METHODS: We retrospectively collected data of malignant MCA infarction patients requiring DH at King Abdulaziz University Hospital & King Faisal Specialist Hospital & Research Center, Jeddah, Kingdom of Saudi Arabia between October 2010 and July 2015. Clinical outcome was assessed immediately postoperatively using Glasgow Coma Score (GCS), and at 12 months using the modified Rankin scale (mRS) and Barthel index. Survival was evaluated at thirty-days and one year after surgery. RESULTS: Six out of 10 patients diagnosed with malignant MCA infarction underwent DH. Among the surgically treated patients (n=6), 4 were males (66%), and the median age was 22.5 years. The median time from admission to surgery was 35.5 hours. The median post-operative GCS was 6.5. Three patients (50%) died within 30 days of DH. In those who survived, the median mRS was 4.5 and BI was 7.5. CONCLUSION: Decompressive hemicraniectomy saves life and has the potential of improving survival functional outcome when done fast and in carefully selected patients. We call for national awareness of the management of such cases and early intervention.

Prenatal solid tumor volume index: novel prenatal predictor of adverse outcome in sacrococcygeal teratoma.

BACKGROUND: Sacrococcygeal teratoma is the most common neonatal tumor. Fetuses with large tumors may develop hydrops from a high cardiac output state (HCOS) and progress rapidly to fetal demise. We postulate that the prenatal solid tumor volume index (STVI), or the ratio of solid tumor volume to the estimated fetal weight (EFW), has greater impact than the total tumor volume in outcome prediction. METHODS: A retrospective chart review of all sacrococcygeal teratoma patients (n = 38) between 2005 and 2012 was conducted. Total tumor volume and percent of solid component were calculated by magnetic resonance imaging and then normalized by dividing them by either head circumference or EFW. Outcomes measured were survival, hydrops or high cardiac output state, defined as a combined ventricular output of >625 mL/min/kg with abnormal Doppler or echocardiogram findings. RESULTS: Thirty-one patients were included in the study. All deaths (n = 7) had either high cardiac output state or hydrops. At a total tumor volume/EFW >0.16, the patient was 17 times more likely to develop HCOS/hydrops (P = 0.001) with 81.25% sensitivity and 86.67% specificity. At a STVI >0.09, the patient was 120 times more likely to develop HCOS/hydrops (P < 0.0001) with 81.25% sensitivity and 100% specificity. CONCLUSIONS: While total tumor volume aids in stratifying patients into high risk categories, STVI (solid tumor volume/EFW) is a better predictor of adverse outcomes. This data will allow us to identify patients who are high risk for cardiac compromise and guide appropriate therapy.

Mirror syndrome in a Chinese hospital: diverse causes and maternal fetal features.

OBJECTIVE: To investigate the clinical characteristics of mirror syndrome. METHODS: Retrospective analysis of cases with mirror syndrome. Data of clinical manifestations, laboratory examinations, placental morphology, treatment and prognosis of these patients were obtained and studied. RESULTS: Five cases satisfying the inclusion criteria for mirror syndrome were identified from our hospital database. The incidence of the condition was 0.0154% in China. Mirror syndrome was associated with Rhesus isoimmunization, intrauterine parvovirus B19 infection, fetal neuroblastoma, fetal heart malformation and unknown cause respectively. Fetal symptoms were multi-hydrocele and fetal heart failure complicating fetal hydrops. All of the cases manifested maternal hydrops and hemodilution, the other most common symptoms included hypertension, proteinuria, hypoalbuminemia, anemia, thrombocytopenia and elevated uric acid levels. Fetal outcomes in this study were poor with a perinatal mortality rate of 100%. Placentomegaly was observed in most cases and placental morphology showed villous edema, increased intervillous fibrin deposition and one rare case of fetal adrenal neuroblastoma. Resolution of maternal symptoms was noted within 3-30 days after delivery. CONCLUSION: Mirror syndrome is associated with a substantially increased risk of fetal death and severe maternal complications. Early diagnosis of this condition during pregnancy is crucial for providing proper treatments and achieving better clinical outcomes.

Mortalidade materna e sua interface com a raça em Mato Grosso / Maternal mortality and race in the Brazilian State of Mato Grosso

Analisar a correlação entre óbitos maternos e raça/cor no Estado de Mato Grosso entre os anos de 2000 a 2006. MÉTODOS: estudo epidemiológico com base nos dados da Declaração de Óbitos, DATASUS e SIM/SES-MT, que propiciaram a análise da série histórica entre esses anos. Relacionou-se raça/cor das mulheres que foram a óbito por causas maternas com as variáveis idade, escolaridade, estado civil, causa básica de óbito e tipo de causa obstétrica. Utilizaram-se teste de Χ2 e odds ratio. RESULTADOS: o teste Χ2 evidenciou associação significativa entre raça/cor e morte materna, ao nível de significância de 95 por cento. A odds ratio apontou uma razão de chances dessas mortes 5,13 vezes maior para mulheres pretas e 5,71 para indígenas, comparadas às mulheres brancas. 'Transtornos hipertensivos da gravidez, parto/puerpério' foram a principal causa de óbito materno para as afrodescendentes e pardas; respectivamente 45,4 por cento e 29,93 por cento. As indígenas morreram mais pelas 'complicações do trabalho de parto/parto' com 27,2 por cento. Das mulheres brancas, 30,7 por cento morreram por 'outras complicações obstétricas não classificadas em outras causas'. CONCLUSÕES: em todo Mato Grosso as mortes maternas por causas obstétricas diretas pervaleceu entre mulheres pretas e indígenas...

To examine the correlation between maternal mortality rates and race/color in the Brazilian State of Mato Grosso between 2000 and 2006. METHODS: an epidemiological study was carried out using the death certificates, DATASUS and SIM/SES-MT to provide a time series for these years. The race/color of the women who died during childbirth was related to the variables age, level of education, marital status, primary cause of death and type of obstetric cause. In combination with the Χ2 test and the odds rati were used. RESULTS: the Χ2 test showed a significant association between race/color and maternal mortality, with a level of significance of 95 percent. The odds ratio revealed that such deaths were 5.13 times more likely among black women and 5.71 times more likely among indigenous women, compared to white women. 'Hypertensive disorders during pregnancy, childbirth or puerperium' were the main cause of maternal mortality among African Brazilian women and women of mixed race; 45.4 percent and 29.93 percent respectively. Indigenous women died more of 'complications during labor' with 27.2 percent. White women died more (30.7 percent) of 'other obstetric complications'. CONCLUSIONS: in the state of Mato Grosso a high maternal mortality rate from direct obstetric causes are found among black and indigenous women...

The correlation of fluid balance changes during cardiopulmonary bypass to mortality in pediatric and congenital heart surgery patients.

Edema acquired during the perioperative period has long been associated with increased mortality. Edema acquired during cardiopulmonary bypass (CPB) may contribute to this mortality. The intent of this retrospective study was to test the premise that edema in the form of a positive fluid balance change (FBC) acquired during CPB correlated to mortality. If so, FBC from the beginning of CPB (baseline; FBC = 0) to the end of CPB may need to be monitored, measured, and controlled on CPB with the same ardor as blood pressure and pH. This retrospective analysis reviewed the FBC of 1540 pediatric and congenital heart surgery patients at the end of CPB. Additions and subtractions of fluid to the combined patient/CPB circuit were routinely quantified during CPB procedures and during periods of modified ultrafiltration (MUF). The primary outcome assessed was mortality during hospitalization. The overall mortality of the 1540 patients was 5.65% from all causes. Eighty percent (n = 1226, mortality = 4.65%) of the patients had a zero or negative FBC immediately after CPB/MUF. Twenty percent (n = 314, mortality = 9.55%) had a positive FBC. Positive FBC patients tended to be in higher risk categories, weighed more, and had longer pump times (p < .05) with an adjusted odds ratio for mortality of 1.73 (1.01-2.96, 95% confidence interval). There is a correlation between edema acquired during CPB and increased mortality in pediatric and congenital heart surgery patients. The potential exists for the perfusionist to optimize the fluid balance changes while on CPB to reduce mortality rates.

Incidence and risk factors for cutaneous adverse drug reactions in an intensive care unit / Incidencia y factores de riesgo en las reacciones adversas medicamentosas de tipo cutáneo en la unidad de cuidados intensivos

Objective. To evaluate the incidence of adverse cutaneous drug reactions in intensive care unit patients. Design. Cohort study. Setting. General adult intensive care unit of an institutional tertiary care hospital. Patients. Patients in the intensive care unit during a consecutive 8-month period were examined for adverse cutaneous drug reactions. Results. Patients in the intensive care unit have an incidence of 11.6% of adverse cutaneous drug reactions. Associated risk factors were female gender, obesity, age over 60 and immune dysregulation (systemic lupus erythematosus, dysthyroidism, and antiphospholipid antibodies syndrome). Few patients had previous history of adverse cutaneous drug reactions. Antimicrobials were the main drug involved. Morbilliform rash followed by urticary were the most frequently observed reactions. Interestingly, over 50% of patients with massive edema -independent of etiology- died. Conclusions. Intensive care unit patients are particularly at risk for developing an adverse cutaneous drug reaction.

Se realizó un estudio de cohorte en la Unidad de Terapia Intensiva (UTI) de un hospital de tercer nivel para evaluar la incidencia de reacciones cutáneas adversas a drogas. Se examinaron todos los pacientes internados en dicha unidad durante un periodo consecutivo de ocho meses. Observamos una incidencia de reacciones adversas a medicamentos de 11.6%. Los factores de riesgo asociados fueron sexo femenino, obesidad, edad mayor a 60 años y alteraciones inmu-nológicas (lupus eritematoso sistémico, distiroidismo y síndrome de antifosfolípido). Los antimicrobianos fueron los principales medicamentos involucrados. La erupción morbiliforme y la urticaria fueron las reacciones más frecuentes. Un hallazgo interesante fue que más de 50% de los pacientes con anasarca fallecieron. Concluimos que los pacientes internados en la UTI son particularmente susceptibles para desarrollar una reacción adversa cutánea a medicamentos.

Pancreatic exocrine enzymes and intrapancreatic protein synthesis in acute oedematous pancreatitis.

Changes in serum and intrapancreatic enzyme content and protein synthesis in pancreas were studied in acute oedematous pancreatitis (AOP). Male Wistar rats (n = 111) were divided into 2 groups, controls with a sham operation and those with AOP. Serum amylase levels rose immediately after the procedure causing AOP and then fell gradually, while serum lipase and ribonuclease levels remained higher than control values over 48 h. (p < 0.05, 0.01). Serum deoxyribonuclease (DNase) II levels were unchanged. Intrapancreatic enzyme levels were scarcely affected by AOP. 3H-leucine uptake into pancreatic tissue of rats with AOP was decreased throughout the study (p < 0.001), but some protein synthesis continued. Intrapancreatic enzyme contents are maintained despite diffusion into the blood because the pancreas retain its ability to synthesize enzymes.

[Individual prognosis in patients with an edematous variant of breast cancer]. / Individual'nyi prognoz u bol'nykh otechnoi formoi raka molochnoi zhelezy.

The probability procedure of Neuman -Pearson (method of maximal credibility) was used for the quantitative description of factors of prognosis of edematous form of breast cancer in terms of specific gravities . A complex evaluation of these factors was carried out. The reliability of prognosis made on the basis of the factors under study was as high as 79%.

Nonimmunologic hydrops fetalis.

Eight cases of nonimmunologic hydrops fetalis (HF) were seen at Cedars-Sinai Medical Center over a 3.5-year period. The etiology of the HF included 2 cases of fetal-maternal hemorrhage and 1 each of sacral teratoma, tachyarrhythmia, diaphragmatic hernia, neuroblastoma, and heart disease. For 1 infant, the cause was never found. These cases involved various diagnostic and therapeutic dilemmas. Only 4 were anticipated ant partum by ultrasound scanning. Two of the 8 fetuses died in utero, whereas 4 others died in the neonatal period. Earlier diagnosis and evaluation are likely to improve these outcomes.

Fatal massive edema of the head and neck secondary to scalp laceration: report of case.

A case of fatal massive edema of the head and neck secondary to subgaleal involvement from a scalp laceration has been presented. Subgaleal infections have been rare since the advent of antibiotics. The unusual and serious nature of the condition is made evident, with considerations of differential diagnosis included.