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

OBJECTIVE: Few studies investigating associations between fine particulate air pollution and hemorrhagic stroke have considered subtypes. Additionally, less is known about the modification of such association by factors measured at the individual level. We aimed to investigate the risk of fatal intracerebral hemorrhage (ICH) incidence in case of PM (particles ≤ 2.5 μm in aerodynamic diameter) exposure. METHODS: Data on incidence of fatal ICH from 1 June 2012 to 31 May 2014 were extracted from the acute stroke mortality database in Shanghai Municipal Center for Disease Control and Prevention (SCDC). We used the time-stratified case-crossover approach to assess the association between daily concentrations of PM and fatal ICH incidence in Shanghai, China. RESULTS: A total of 5286 fatal ICH cases occurred during our study period. The averaged concentration of PM was 77.45 μg/m. The incidence of fatal ICH was significantly associated with PM concentration. Substantial differences were observed among subjects with diabetes compared with those without; following the increase of PM in lag2, the OR (95% CI) for subjects with diabetes was 1.26 (1.09-1.46) versus 1.05 (0.98-1.12) for those without. We did not find evidence of effect modification by hypertension and cigarette smoking. CONCLUSIONS Fatal ICH incidence was associated with PM exposure. Our results also suggested that diabetes may increase the risk for ICH incidence in relation to PM.
Air Pollutants ; analysis ; Cause of Death ; Cerebral Hemorrhage ; mortality ; China ; epidemiology ; Diabetes Mellitus ; mortality ; Environmental Exposure ; statistics & numerical data ; Female ; Humans ; Incidence ; Male ; Particle Size ; Particulate Matter ; analysis ; Stroke ; mortality

Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient's safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.
Cooperative Behavior ; Education ; Health Care Costs ; Hemorrhage ; Humans ; Interdisciplinary Communication ; Methods ; Mortality ; Organization and Administration ; Patient Safety ; Point-of-Care Systems ; Precision Medicine ; Technology Assessment, Biomedical ; Thrombelastography

mortality of trauma patients with severe hemorrhage.METHODS: Seventeen relevant articles were obtained by searching the PubMed databases through February 15, 2019. The estimated mortality rates and injury severity scores were obtained through a meta-analysis. In addition, diagnostic test accuracy (DTA) reviews were conducted to obtain the sensitivity, specificity, diagnostic odds ratio, and the summary receiver operating characteristic curve.RESULTS: At 24 hours, the estimated mortality rates were 0.194, 0.126, and 0.168 in assessments using MT, CAT, and RI, respectively. In addition, the pooled sensitivity of CAT (0.89; 95% confidence interval [CI], 0.82–0.94) was significantly higher than that of MT (0.63; 95% CI, 0.57–0.68) and RI (0.69; 95% CI, 0.63–0.75). Overall, the pooled specificity of MT and CAT was 0.82 (95% CI, 0.80–0.83) and 0.85 (95% CI, 0.83–0.88), respectively, while the pooled sensitivity was 0.49 (95% CI, 0.44–0.54) and 0.50 (95% CI, 0.38–0.62), respectively.CONCLUSION: CAT may be a more sensitive predictor for 24-hour mortality than other predictors. Furthermore, RI also appears to be a useful predictor for 24-hour mortality. Both MT and CAT showed high specificity for overall mortality.]]>
Animals ; Cats ; Diagnostic Tests, Routine ; Hemorrhage ; Humans ; Injury Severity Score ; Mortality ; Odds Ratio ; Resuscitation ; ROC Curve ; Sensitivity and Specificity

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

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