Analysis of the SHARPEN Score in the Prediction of In-Hospital Mortality of Patients With Infective Endocarditis Undergoing Cardiac Surgery

Abstract Background The SHARPEN score was developed to predict in-hospital mortality in patients hospitalized for infective endocarditis (IE), undergoing or not undergoing cardiac surgery. A comparison with other available scores has not yet been carried out. Objective To evaluate the performance of the SHARPEN score in predicting in-hospital mortality in patients hospitalized for IE undergoing cardiac surgery and compare it with that of both nonspecific and IE-specific surgical scores. Methods Retrospective cohort study including all admissions of patients ≥18 years who underwent cardiac surgery due to active IE (modified Duke criteria) at a tertiary care university hospital between 2007 and 2016. The SHARPEN score was compared to the EuroSCORE, EuroSCORE II, STS-IE, PALSUSE, AEPEI, EndoSCORE and RISK-E scores. Differences P<0.05 were considered statistically significant. Results A total of 105 hospitalizations of 101 patients (mean age 57.4±14.6 years; 75.2% male) were included. The median SHARPEN score was 11 (9-13) points. The observed in-hospital mortality was 29.5%. There was no statistically significant difference in observed vs. estimated mortality (P = 0.147), with an area under the ROC curve of 0.66 (P = 0.008). In comparison with the other scores, no difference was observed in discriminative ability. The statistics of the SHARPEN score at a cutoff >10 points — positive predictive value (PPV): 38.1%, 95%CI:30.4-46.6; negative predictive value (NPV): 80.0%, 95%CI:69.8-87.4; and accuracy: 58.1%, 95%CI:48.1-67.6 — showed overlapping 95%CIs, indicating no significant difference between scores. Conclusions The SHARPEN score did not present parameters with a significant difference in relation to the other scores analyzed; despite the easy obtainment of its few variables, it has limited applicability in clinical practice, like other existing scores.

An overview of care change in the last 6 year in primary PCI in ST-elevation myocardial infarction in a Tertiary University Brazilian Hospital / Panorama da mudança do cuidado nos últimos 6 anos na ICP primária em infarto agudo do miocárdio com supradesnivelamento do segmento ST em hospital universitário de nível terciário

Background: Although new studies and guidelines can be considered useful tools, it does not necessarily mean they are put into clinical practice. Objective: The aim of the current analysis was to assess the changes in primary percutaneous coronary intervention (PCI) and mortality in a tertiary university hospital in southern Brazil during a six-year period .Methods: We have included consecutive patients with ST-elevation myocardial infarction (STEMI) who underwent primary PCI between March 2011 and February 2017. Previous clinical history, characteristics of the procedure, and reperfusion strategies were collected. In-hospital, short and long-term mortalities were also evaluated. The significance level adopted for all tests was 5%. Results: There was an increase in the use of radial access in patients from 20.0% in 2011 to 62.7% in 2016 (ptrend < 0.0001). Moreover, thrombus aspiration decreased significantly from 66.7% in 2011 to less than 3.0% in 2016 (ptrend < 0.0001). In-hospital, short and long-term mortalities remained reasonably stable from 2011 to 2016 (ptrend > 0.05). However, a lower in-hospital mortality was observed in patients treated through radial access (p < 0.001). Cardiogenic shock occurred in 11.1%, without statistical differences in the period (ptrend = 0.39), while long-term mortality rate decreased from 80.0% in 2011 to 27.3% in 2016 in this patient group (ptrend = 0.29). Conclusions: During a 6-year follow-up period, primary PCI characteristics underwent important modifications. Radial access became widely used, with a decrease in mortality with the use of this route, while aspiration thrombectomy became a rare procedure. The incidence of cardiogenic shock remained stable, but has shown a reduction in its mortality

Intramuscular electrical stimulus potentiates motor cortex modulation effects on pain and descending inhibitory systems in knee osteoarthritis: a randomized, factorial, sham-controlled study.

BACKGROUND: Neuroplastic changes in nociceptive pathways contribute to severity of symptoms in knee osteoarthritis (KOA). A new look at neuroplastic changes management includes modulation of the primary motor cortex by transcranial direct current stimulation (tDCS). OBJECTIVES: We investigated whether tDCS combined with intramuscular electrical stimulation (EIMS) would be more efficacious than a sham (s) intervention (s-tDCS/s-EIMS) or a single active(a)-tDCS/s-EIMS intervention and/or s-tDCS/a-EIMS in the following domains: pain measures (visual analog scale [VAS] score and descending pain modulatory system [DPMS], and outcomes, and analgesic use, disability, and pain pressure threshold (PPT) for secondary outcomes. REGISTRATION: The trial is registered in Clinicaltrials.gov: NCT01747070. METHODS: Sixty women with KOA, aged 50-75 years old, randomly received five sessions of one of the four interventions (a-tDCS/a-EIMS, s-tDCS/s-EIMS, a-tDCS/s-EIMS, and s-tDCS/a-EIMS). tDCS was applied over the primary motor cortex (M1), for 30 minutes at 2 mA and the EIMS paraspinal of L1-S2. RESULTS: A generalized estimating equation model revealed the main effect of the a-tDCS/a-EIMS in the VAS pain scores at end treatment compared with the other three groups (P<0.0001). There existed a significant effect of time and a significant interaction between group and time (P<0.01 for both). The delta-(Δ) pain score on VAS in the a-tDCS/a-EIMS group was -3.59, 95% CI: -4.10 to -2.63. The (Δ) pain scores on VAS in the other three groups were: a-tDCS/s-EIMS=-2.13, 95% CI: -2.48 to -1.64; s-tDCS/a-EIMS=-2.25, 95% CI: -2.59 to -1.68; s-tDCS/s-EIMS MR =-1.77, 95% CI: -2.08 to -1.38. The a-tDCS/a-EIMS led to better effect in DPMS, PPT, analgesic use, and disability related to pain. CONCLUSION: This study provides additional evidence regarding additive clinical effects to improve pain measures and descending pain inhibitory controls when the neuromodulation of the primary motor cortex with tDCS is combined with a bottom-up modulation with EIMS in KOA. Also, it improved the ability to walk due to reduced pain and reduced analgesic use.

Elevated neutrophil-to-lymphocyte ratio can predict procedural adverse events in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: Elevated neutrophil-to-lymphocyte ratio (NLR) is an indirect marker of inflammation, and is associated with adverse clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate the usefulness of NLR to predict procedural adverse events is patients who underwent primary percutaneous coronary intervention (PCI). PATIENTS AND METHODS: Consecutive patients with STEMI who underwent primary PCI were divided into low and high NLR, whereas high was defined as an NLR value above 75° percentile (≥9.45). The occurrence of procedural complications, in-hospital, and 30-day major adverse cardiovascular events and 1-year all-cause mortality were evaluated. RESULTS: We included 664 patients with a mean age of 60.5 (±12.1) years and 66.3% were male. In multivariate analysis, NLR remained an independent predictor of in-hospital death [relative risk (RR)=1.03; 95% confidence interval (CI)=1.00-1.08; P=0.04], contrast-induced nephropathy (RR=2.35; 95% CI=1.11-4.71; P=0.02), distal embolization (RR=2.72; 95% CI=1.55-4.75; P<0.001), and no-reflow (RR=2.31; 95% CI=2.31-4.68; P=0.01). The area under the curve for distal embolization was 0.67, 0.64 for no-reflow and 0.62 for procedural complications. A low value of NLR had an excellent negative predictive value of 97.8, 96.9, and 92.1 for distal embolization, no-reflow, and procedural complications, respectively. CONCLUSION: High NLR is an independent predictor of distal embolization, no-reflow, and procedural complications in patients with STEMI who underwent primary PCI. A low NLR value has an excellent negative predictive value for these procedural outcomes. NLR may be a useful and inexpensive tool that may be used at bedside.

Comparison of neutrophil-to-lymphocyte ratio and mean platelet volume in the prediction of adverse events after primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction.

BACKGROUND AND AIMS: Elevated neutrophil-to-lymphocyte ratio (NLR) and mean platelet volume (MPV) are indirect inflammatory markers. There is some evidence that both are associated with worse outcomes in ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PCI). The aim of the present study was to compare the capacity of NLR and MPV to predict adverse events after primary PCI. METHODS: In a prospective cohort study, 625 consecutive patients with STEMI, who underwent primary PCI, were followed. Receiver operating characteristic (ROC) curve analysis was performed to calculate the area under the curve (AUC) for the occurrence of procedural complications, mortality and major adverse cardiovascular events (MACE). RESULTS: Mean age was 60.7 (±12.1) years, 67.5% were male. The median of NLR was 6.17 (3.8-9.4) and MPV was 10.7 (10.0-11.3). In multivariate analysis, both NLR and MPV remained independent predictors of no-reflow (relative risk [RR] = 2.26; 95%confidence interval [95%CI] = 1.16-4.32; p = 0.01 and RR = 2.68; 95%CI = 1.40-5.10; p < 0.01, respectively), but only NLR remained an independent predictor of in-hospital MACE (RR = 1.01; 95%CI = 1.00-1.06; p = 0.02). The AUC for in-hospital MACE was 0.57 for NLR (95%CI = 0.53-0.60; p = 0.03) and 0.56 for MPV (95%CI = 0.52-0.60; p = 0.07). However, when AUC were compared with DeLong test, there was no statistically significant difference for these outcomes (p > 0.05). NLR had an excellent negative predictive value (NPV) of 96.7 for no-reflow and 89.0 for in-hospital MACE. CONCLUSIONS: Despite no difference in the ROC curve comparison with MPV, only NLR remained an independent predictor for in-hospital MACE. A low NLR has an excellent NPV for no-reflow and in-hospital MACE, and this could be of clinical relevance in the management of low-risk patients.