BACKGROUND AND OBJECTIVE

A growing body of evidence supports that inflammatory mechanisms are involved in secondary brain injury after intracerebral hemorrhage (ICH) which has implications on the morbidity and mortality of stroke patients. Neutrophil-to-lymphocyte ratio (NLR) is a comprehensive index marker of inflammation and immune status of a patient. The prognostic value of NLR in predicting in-hospital mortality and functional outcome of patients with spontaneous intracerebral hemorrhage will be assessed in this study.

We retrospectively selected 151 hemorrhagic stroke patients, and demographic and clinical characteristics were collected and computed for NLR. Receiver operating characteristic analysis using Youden’s index was utilized to determine the NLR cut-off value with the best sensitivity and specificity. The association of NLR with the inhospital mortality and functional outcome was assessed using Logistic regression analysis. Pearson Product Model Correlation was employed to evaluate the correlation of NLR with ICH volume.

Admission NLR >7 showed a significant association (p = <0.001 OR 7.99) with in-hospital mortality with a sensitivity of 70.83% and specificity of 72.82%. Furthermore, computed NLR of more than 6.4 showed significant association (p = 0.040 OR 2.92) with poor functional outcome. However, our study revealed that admission NLR showed a low level of correlation (r=0.2968, p=0.002) with the volume of ICH.

This study demonstrated that ICH patients with an elevated NLR is associated with increased inhospital mortality and poor functional outcome and that NLR can be used to predict clinical outcome among patients with spontaneous ICH.

BACKGROUND

There is ambiguity on antiplatelet therapy for post-transcatheter aortic valve replacement (TAVR) patients for stroke prevention, but dual antiplatelet therapy (DAPT) is routinely started despite lack of data on effectiveness and bleeding safety of DAPT versus single antiplatelet therapy (SAPT). This study aims to determine the effectiveness of DAPT versus SAPT in stroke prevention and assess bleeding safety.

A systematic search was done for randomized clinical trials involving DAPT and SAPT in patients who underwent TAVR. The primary outcome was stroke after 1 year of either DAPT and SAPT and life-threatening bleeding. Secondary end points included all-cause mortality. Trials were identified through systematic searches on the following databases (November 2019): Cochrane, MEDLINE, and Google Scholar and ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform. Risk ratio was used for dichotomous outcomes. Heterogeneity among the studies for the meta-analysis was detected using a χ2 test (0.01 level of significance). Risk-of-bias assessment was done.

There is a lower incidence of stroke in patients on DAPT, but with a higher incidence of life-threatening bleeding and major bleeding. There is also a lower incidence of all-cause mortality in SAPT. The statistical power of this meta-analysis is low due to small population size.

Single antiplatelet therapy is comparable to DAPT in preventing stroke with the added benefit of a lower incidence of life-threatening and major bleeding and a lower incidence of all-cause mortality.

mortality.RESULTS: During the therapeutic period, there were no significant differences between the groups in the proportion of composite events, recurrence, or clinically relevant bleeding. Multivariate analysis using the Cox proportional hazards model also showed no significant difference in the number of composite events and clinically relevant bleeding between the groups. In the rivaroxaban group, 44.0% of patients experienced gastrointestinal bleeding and 24.0% experienced urinary tract bleeding. In the dalteparin group, bleeding was most common in the urinary tract (44.4%) and at the injection site (22.2%).CONCLUSION: In this study, although there were no significant differences in effectiveness or safety between the rivaroxaban and dalteparin groups, rivaroxaban use was associated with a higher rate of clinically relevant bleeding than dalteparin. Therefore, caution should be taken when prescribing rivaroxaban for gynecologic cancer-associated VTE and bleeding events should be carefully monitored.]]>
Anticoagulants ; Dalteparin ; Hemorrhage ; Heparin ; Humans ; Mortality ; Multivariate Analysis ; Proportional Hazards Models ; Recurrence ; Rivaroxaban ; Urinary Tract ; Venous Thromboembolism

mortality.RESULTS: A total of 455 strains were isolated from 432 ascitic culture samples. Gram-negative bacteria (GNB), gram-positive bacteria (GPB), and fungi caused 52.3, 45.5, and 2.2% of all SAI episodes, respectively. Episodes were classified as nosocomial (41.2%), healthcare-related (34.7%), and community-acquired (24.1%). Escherichia coli (13.4%) and Klebsiella pneumoniae (2.4%) were extended-spectrum β-lactamase producing isolates. The prevalence of methicillin-resistant Staphylococcus aureus was 1.1%. Ceftazidime, cefepime, aztreonam, and amikacin were recommended as first-line antibiotics agents for non-MDR GNB infections; piperacillin/tazobactam and carbapenems for MDR GNB in community-acquired and healthcare-related or nosocomial infections, respectively; and vancomycin or linezolid for GPB infections, regardless of drug-resistance status. Multivariate analysis revealed days of hospital stay before SAI, upper gastrointestinal bleeding, white blood cell count, alanine aminotransferase, serum creatinine concentration, total bilirubin, and international normalized ratio as key independent predictors of 28-day mortality.CONCLUSION: MDR pathogens and antibiotic strategies were identified in patients with acute decompensated cirrhosis with culture-positive SAI, which may help optimize therapy and improve clinical outcomes.]]>
Alanine Transaminase ; Amikacin ; Anti-Bacterial Agents ; Aztreonam ; Bilirubin ; Carbapenems ; Ceftazidime ; China ; Creatinine ; Cross Infection ; Escherichia coli ; Fibrosis ; Fungi ; Gram-Negative Bacteria ; Gram-Positive Bacteria ; Hemorrhage ; Hospitals, Teaching ; Humans ; International Normalized Ratio ; Klebsiella pneumoniae ; Length of Stay ; Leukocyte Count ; Linezolid ; Methicillin-Resistant Staphylococcus aureus ; Mortality ; Multivariate Analysis ; Prevalence ; Proportional Hazards Models ; Retrospective Studies ; Risk Factors ; Vancomycin

Background: Subarachnoid hemorrhage is a devastating type of stroke with high mortality rate. The understanding of factors that contribute to mortality in patient with subarachnoid hemorrhage can help clinicians in further management of the patients. Aim: The aim of this study is to identify mortality risk factors in patients with subarachnoid hemorrhage (SH). Methods: This study is a retrospective cohort study. Data were obtained from the stroke registry and medical records of patients at Bethesda Hospital Yogyakarta. Data were analyzed using univariate, bivariate and multivariate logistic regression analysis. Results: Data were obtained from 80 subarachnoid hemorrhage patients consisting of 40 males (50%) and 40 females (50%). Result of multivariate analysis show that there are significant associations between mortality in SAH patient with loss of consciousness (OR: 19.722, 95% CI: 1.788- 217.521, p: 0.015), elevated systolic blood pressure (OR: 157.4, 95%CI: 2.068- 11990.9, p: 0.022), high random blood glucose (OR: 12.457, 95%CI: 2.305- 67.322, p: 0.03) and presence of medical complication (OR: 30.539, CI95%: 2.685- 347.377, p: 0.006). Conclusion This study demonstrated that loss of consciousness, elevated systolic blood pressure, high blood glucose, and presence of medical complication has significant association with mortality of SAH patient.
Mortality ; Prognosis ; Subarachnoid Hemorrhage

PURPOSE: To evaluate superiority of a night float (NF) system in comparison to a traditional night on-call (NO) system for surgical residents at a single institution in terms of efficacy, safety, and satisfaction. METHODS: A NF system was implemented from March to September 2017 and big data analysis from electronic medical records was performed for all patients admitted for surgery or contacted from the emergency room (ER). Parameters including vital signs, mortality, and morbidity rates, as well as promptness of response to ER calls, were compared against a comparable period (March to September 2016) during which a NO system was in effect. A survey was also performed for physicians and nurses who had experienced both systems. RESULTS: A total of 150,000 clinical data were analyzed. Under the NO and NF systems, a total of 3,900 and 3,726 patients were admitted for surgery. Mortality rates were similar but postoperative bleeding was significantly higher in the NO system (0.5% vs. 0.2%, P = 0.031). From the 1,462 and 1,354 patients under the NO and NF systems respectively, that required surgical consultation from the ER, the time to response was significantly shorter in the NF system (54.5 ± 70.7 minutes vs. 66.8 ± 83.8 minutes, P < 0.001). Both physicians (90.4%) and nurses (91.4%) agreed that the NF system was more beneficial. CONCLUSION: This is the first report of a NF system using big data analysis in Korea, and potential benefits of this new system were observed in both ward and ER patient management.
Electronic Health Records ; Emergency Service, Hospital ; Hemorrhage ; Humans ; Internship and Residency ; Korea ; Medical Staff ; Mortality ; Statistics as Topic ; Vital Signs

Despite the great socioeconomic burden of stroke, there have been few reports of stroke statistics in Korea. In this scenario, the Epidemiologic Research Council of the Korean Stroke Society launched the “Stroke Statistics in Korea” project, aimed at writing a contemporary, comprehensive, and representative report on stroke epidemiology in Korea. This report contains general statistics of stroke, prevalence of behavioral and vascular risk factors, stroke characteristics, pre-hospital system of care, hospital management, quality of stroke care, and outcomes. In this report, we analyzed the most up-to-date and nationally representative databases, rather than performing a systematic review of existing evidence. In summary, one in 40 adults are patients with stroke and 232 subjects per 100,000 experience a stroke event every year. Among the 100 patients with stroke in 2014, 76 had ischemic stroke, 15 had intracerebral hemorrhage, and nine had subarachnoid hemorrhage. Stroke mortality is gradually declining, but it remains as high as 30 deaths per 100,000 individuals, with regional disparities. As for stroke risk factors, the prevalence of smoking is decreasing in men but not in women, and the prevalence of alcohol drinking is increasing in women but not in men. Population-attributable risk factors vary with age. Smoking plays a role in young-aged individuals, hypertension and diabetes in middle-aged individuals, and atrial fibrillation in the elderly. About four out of 10 hospitalized patients with stroke are visiting an emergency room within 3 hours of symptom onset, and only half use an ambulance. Regarding acute management, the proportion of patients with ischemic stroke receiving intravenous thrombolysis and endovascular treatment was 10.7% and 3.6%, respectively. Decompressive surgery was performed in 1.4% of patients with ischemic stroke and in 28.1% of those with intracerebral hemorrhage. The cumulative incidence of bleeding and fracture at 1 year after stroke was 8.9% and 4.7%, respectively. The direct costs of stroke were about ₩1.68 trillion (KRW), of which ₩1.11 trillion were for ischemic stroke and ₩540 billion for hemorrhagic stroke. The great burden of stroke in Korea can be reduced through more concentrated efforts to control major attributable risk factors for age and sex, reorganize emergency medical service systems to give patients with stroke more opportunities for reperfusion therapy, disseminate stroke unit care, and reduce regional disparities. We hope that this report can contribute to achieving these tasks.
Adult ; Aged ; Alcohol Drinking ; Ambulances ; Atrial Fibrillation ; Cerebral Hemorrhage ; Emergency Medical Services ; Emergency Service, Hospital ; Epidemiology ; Female ; Hemorrhage ; Hope ; Humans ; Hypertension ; Incidence ; Korea ; Male ; Mortality ; Prevalence ; Reperfusion ; Risk Factors ; Smoke ; Smoking ; Stroke ; Subarachnoid Hemorrhage ; Writing

BACKGROUND: The primary goal of this study was to characterize the clinical outcomes of adult patients with hematologic malignancies (HM) who were treated with extracorporeal membrane oxygenation (ECMO) support when conventional treatments failed. METHODS: In this retrospective, observational study at a tertiary medical center, we reviewed the clinical course of 23 consecutive patients with HM requiring ECMO who were admitted to the intensive care unit at Asan Medical Center from March 2010 to April 2015. RESULTS: A total of 23 patients (8 female; median age, 44 years; range, 29–51 years) with HM and severe acute circulatory and/or respiratory failure received ECMO therapy during the study period. Fourteen patients received veno-arterial ECMO, while 9 patients received veno-venous ECMO. The median ECMO duration was 104.7 hours (range, 37.1–221 hours). Nine patients were successfully weaned from ECMO. The in-hospital mortality rate was 91.1% (21 of 23). There were complications in 3 patients (cannulation site bleeding, limb ischemia, and gastrointestinal bleeding). CONCLUSION: ECMO is a useful treatment for patients with circulatory and/or pulmonary failure. However, in patients with HM, the outcomes of ECMO treatment results were very poor, so it is advisable to carefully decide whether to apply ECMO to these patients.
Adult ; Chungcheongnam-do ; Extracorporeal Membrane Oxygenation ; Extremities ; Female ; Hematologic Neoplasms ; Hemorrhage ; Hospital Mortality ; Humans ; Intensive Care Units ; Ischemia ; Mortality ; Observational Study ; Respiratory Insufficiency ; Retrospective Studies

BACKGROUND: Although aortic valve repair can reduce prosthesis-related complications, rheumatic aortic regurgitation (AR) caused by leaflet restriction is a significant risk factor for recurrent AR. In this study, we evaluated the long-term results of the leaflet extension technique for rheumatic AR. METHODS: Between 1995 and 2016, 33 patients underwent aortic valve repair using the leaflet extension technique with autologous pericardium for rheumatic pure AR. Twenty patients had severe AR and 9 had combined moderate or greater mitral regurgitation. Their mean age was 32.2±13.9 years. The mean follow-up duration was 18.3±5.8 years. RESULTS: There were no cases of operative mortality, but postoperative complications occurred in 5 patients. Overall survival at 10 and 20 years was 93.5% and 87.1%, respectively. There were no thromboembolic cerebrovascular events, but 4 late deaths occurred, as well as a bleeding event in 1 patient who was taking warfarin. Twelve patients underwent aortic valve reoperation. The mean interval to reoperation was 13.1±6.1 years. Freedom from reoperation at 10 and 20 years was 96.7% and 66.6%, respectively. CONCLUSION: The long-term results of the leaflet extension technique showed acceptable durability and a low incidence of thromboembolic events and bleeding. The leaflet extension technique may be a good option for young patients with rheumatic AR.
Aortic Valve ; Aortic Valve Insufficiency ; Follow-Up Studies ; Freedom ; Hemorrhage ; Humans ; Incidence ; Mitral Valve Insufficiency ; Mortality ; Pericardium ; Postoperative Complications ; Reoperation ; Rheumatic Diseases ; Risk Factors ; Warfarin

OBJECTIVE: Shunt-dependent hydrocephalus (SdHCP) is a well-known complication of aneurysmal subarachnoid hemorrhage (SAH). The risk factors for SdHCP have been widely investigated, but few risk scoring systems have been established to predict SdHCP. This study was performed to investigate the risk factors for SdHCP and devise a risk scoring system for use before aneurysm obliteration.METHODS: We reviewed the data of 301 consecutive patients who underwent aneurysm obliteration following SAH from September 2007 to December 2016. The exclusion criteria for this study were previous aneurysm obliteration, previous major cerebral infarction, the presence of a cavum septum pellucidum, a midline shift of >10 mm on initial computed tomography (CT), and in-hospital mortality. We finally recruited 254 patients and analyzed the following data according to the presence or absence of SdHCP : age, sex, history of hypertension and diabetes mellitus, Hunt-Hess grade, Fisher grade, aneurysm size and location, type of treatment, bicaudate index on initial CT, intraventricular hemorrhage, cerebrospinal fluid drainage, vasospasm, and modified Rankin scale score at discharge.RESULTS: In the multivariate analysis, acute HCP (bicaudate index of ≥0.2) (odds ratio [OR], 6.749; 95% confidence interval [CI], 2.843–16.021; p=0.000), Fisher grade of 4 (OR, 4.108; 95% CI, 1.044–16.169; p=0.043), and an age of ≥50 years (OR, 3.938; 95% CI, 1.375–11.275; p=0.011) were significantly associated with the occurrence of SdHCP. The risk scoring system using above parameters of acute HCP, Fisher grade, and age (AFA score) assigned 1 point to each (total score of 0–3 points). SdHCP occurred in 4.3% of patients with a score of 0, 8.5% with a score of 1, 25.5% with a score of 2, and 61.7% with a score of 3 (p=0.000). In the receiver operating characteristic curve analysis, the area under the curve (AUC) for the risk scoring system was 0.820 (p=0.080; 95% CI, 0.750–0.890). In the internal validation of the risk scoring system, the score reliably predicted SdHCP (AUC, 0.895; p=0.000; 95% CI, 0.847–0.943).CONCLUSION: Our results suggest that the herein-described AFA score is a useful tool for predicting SdHCP before aneurysm obliteration. Prospective validation is needed.
Aneurysm ; Cerebral Infarction ; Cerebrospinal Fluid Leak ; Diabetes Mellitus ; Hemorrhage ; Hospital Mortality ; Humans ; Hydrocephalus ; Hypertension ; Multivariate Analysis ; Prospective Studies ; Risk Factors ; ROC Curve ; Septum Pellucidum ; Subarachnoid Hemorrhage ; Ventriculoperitoneal Shunt