Association between neutrophil-to-lymphocyte ratio in the first seven days of sepsis and mortality

IntroductionThe neutrophil-to-lymphocyte ratio (NLR) in the diagnosis of sepsis has been found to be higher in non-survivors than in survivors, and that is associated with mortality. A higher NLR in non-survivors than in survivors has been reported in two studies during patient follow-up; however, NLR was not controlled for sepsis severity. Thus, the objective of this study was to determine whether there is an association between NLR in the first seven days and mortality controlling for sepsis severity.MethodsThis observational study, which included septic patients, was conducted in the Intensive Care Units of 3 Spanish hospitals. NLR was recorded on the first, fourth, and eighth day of sepsis. Multiple logistic regression analyses were carried out to determine the association between NLR during the first 7 days of sepsis diagnosis and mortality controlling for sepsis severity.ResultsThirty-day non-surviving patients (n = 68) compared to surviving patients (n = 135) showed higher NLR on the first (p < 0.001), fourth (p < 0.001), and eighth (p < 0.001) day of sepsis diagnosis. Multiple logistic regression analysis found an association between NLR at days first (p < 0.001), fourth (p = 0.004), and eighth (p = 0.01) of sepsis diagnosis and mortality controlling for SOFA and lactic acid in those days.ConclusionsThe new finding of our study was the association between NLR in the first seven days of sepsis and mortality controlling for sepsis severity.     

Case – Control study of potential culprit procedures for infective endocarditis in an Egyptian tertiary care center

BackgroundInfective endocarditis (IE) is associated with substantial morbidity and mortality. However, there are conflicting views as to the significance of bacteremia caused by interventional procedures in the existing clinical guidelines.ObjectivesFormal evaluation of risk factors for IE is lacking in Egyptian tertiary care centers. We test the hypothesis that underlying medical conditions, not culprit procedures, are the most important risk factor for development of IE.MethodsWe matched 175 patients with definite IE from IE database of the Cardiology Department, Cairo University Hospital with175 control cases without IE, matched for age, sex, and underlying heart disease. Demographic and clinical data, comorbidities and potential culprit procedures during the 3 months prior to the diagnosis of IE were recorded.ResultsHost-related risk factors included renal impairment (p < 0.001), renal dialysis (p = 0.003) and prior episode of IE (p = 0.03). Procedure-related risk factors included a history of hospitalization for at least 24 h in the preceding 3 months (p < 0.001), and use of peripheral intravenous line (p = 0.005). Dental procedures were not risk factors for IE. Staphylococcus aureus was the most prevalent procedure-related microorganism (27.3 %), followed by Streptococcus species in 15.9% of cases.ConclusionsHospitalization for at least 24 h within the preceding 3 months, peripheral IV line placement, renal impairment and prior IE were significant risk factors for IE. Staphylococci were the predominant microorganisms. These results suggest a nosocomial source of infection and call for reinforcement of infection prevention interventions in Egyptian hospitals especially in high-risk patients.     

Association between biomass formation and the prognosis of infective endocarditis due to Staphylococcus aureus

IntroductionThe aim of this study was to evaluate the association between biomass formation and the clinical characteristics and prognosis of Staphylococcus aureus infective endocarditis (IE).MethodsWe prospectively studied 209 S. aureus strains causing IE. Biomass formation was examined using the crystal violet assay and quantified spectrophotometrically. The average (SD) optical density of the biomass was compared for each clinical, microbiological (methicillin-resistance, vancomycin MIC ≥ 1.5 μg/ml) and molecular (clonal complex, agr type and agr dysfunction) variable according to their presence or absence. The primary clinical endpoints studied were in-hospital death, severe sepsis, persistent bacteraemia, symptomatic peripheral embolisms and prosthetic valve IE.ResultsMean age was 66.1 years, 61.5% of patients were male and the median age-adjusted Charlson comorbidity index was 5 points (IQR 3–8). In-hospital mortality was 37.3%. Strains belonging to CC5 and CC22 had optical biomass densities [mean (SD) 1.573 (1.14) vs 0.942 (0.98) p < 0.001 and 1.720 (0.94) vs 1.028 (1.04) p = 0.001, respectively]. Strains belonging to CC5 and CC22 had significantly higher optical biomass densities [1.369 (1.18) vs 0.920 (0.93) p = 0.008]. No statistically significant differences were found in the clinical endpoints studied.ConclusionsHigh biomass production was associated with CC5 and CC22 but not with higher hospital mortality, septic complications, type of endocarditis, methicillin-resistance, elevated vancomycin MIC or agr dysfunction.     

Association of serum soluble Fas concentrations and mortality of septic patients

IntroductionScarce data on Fas, one of the main receptors that activates the apoptosis extrinsic pathway, in septic patients exists. Higher blood soluble Fas (sFas) concentrations in non-survivor septic patients compared with survivors have been found in small studies; however, the association of blood sFas concentrations with mortality controlling for sepsis severity has not been stablished due to this small sample size in those studies. Thus, our main objective study was to determine whether an association between blood sFas concentrations and sepsis mortality controlling for sepsis severity exists.MethodsWe included septic patients in this observational and prospective study carried out in three Spanish Intensive Care Units. We obtained serum samples at sepsis diagnosis sepsis for sFas levels determination.ResultsThirty-day non-surviving patients (n = 85) compared to surviving patients (n = 151) had higher serum sFas levels (p < 0.001). We found in multiple logistic regression analysis an association of serum sFas levels with mortality controlling for age and SOFA (OR = 1.004; 95% CI = 1.002–1.006; p < 0.001), and for age and APACHE-II (OR = 1.004; 95% CI = 1.002–1.006; p < 0.001). Serum sFas levels showed and area under the curve for mortality prediction of 71% (95% CI = 65–71%; p < 0.001). Kaplan–Meier analysis showed higher mortality rate in patients with serum sFas levels > 83.5 ng/mL (Hazard ratio = 3.2; 95% CI = 2.1–5.0; p < 0.001).ConclusionsThat an association between blood sFas concentrations and sepsis mortality controlling for sepsis severity exists was our main new finding study.     

Modelo predictivo de mortalidad hospitalaria en endocarditis infecciosa izquierda

Introduction and objectivesInfective endocarditis (IE) is a complex disease with high in-hospital mortality. Prognostic assessment is essential to select the most appropriate therapeutic approach; however, international IE guidelines do not provide objective assessment of the individual risk in each patient. We aimed to design a predictive model of in-hospital mortality in left-sided IE combining the prognostic variables proposed by the European guidelines.MethodsTwo prospective cohorts of consecutive patients with left-sided IE were used. Cohort 1 (n = 1002) was randomized in a 2:1 ratio to obtain 2 samples: an adjustment sample to derive the model (n = 688), and a validation sample for internal validation (n = 314). Cohort 2 (n = 133) was used for external validation.ResultsThe model included age, prosthetic valve IE, comorbidities, heart failure, renal failure, septic shock, Staphylococcus aureus, fungi, periannular complications, ventricular dysfunction, and vegetations as independent predictors of in-hospital mortality. The model showed good discrimination (area under the ROC curve = 0.855; 95%CI, 0.825-0.885) and calibration (P value in Hosmer-Lemeshow test = 0.409), which were ratified in the internal (area under the ROC curve = 0.823; 95%CI, 0.774-0.873) and external validations (area under the ROC curve = 0.753; 95%CI, 0.659-0.847). For the internal validation sample (observed mortality: 29.9%) the model predicted an in-hospital mortality of 30.7% (95%CI, 27.7-33.7), and for the external validation cohort (observed mortality: 27.1%) the value was 26.4% (95%CI, 22.2-30.5).ConclusionsA predictive model of in-hospital mortality in left-sided IE based on the prognostic variables proposed by the European Society of Cardiology IE guidelines has high discriminatory ability.     

Hyperuricemia in acute heart failure. More than a simple spectator?

BackgroundHyperuricemia is a prevalent condition in chronic heart failure (CHF), describing increased oxidative stress and inflammation. Although there is evidence that serum uric acid (UA) predicts mortality in CHF, its role as a prognostic biomarker in acute heart failure (AHF) has not yet been well assessed. The aim of this study was to determine if UA levels predict all-cause mortality. Additionally, as a secondary endpoint we sought the clinical predictors of UA serum level in this population.MethodsWe analyzed 560 consecutive patients with AHF admitted in a single university center. UA (mg/dl) was measured during early hospitalization. Patient survival status was followed up after discharge (median follow-up: 330 days). The independent association of UA level with all-cause mortality was analyzed using Cox regression analysis.ResultsDuring follow-up 165 (29.5%) deaths were identified. Patients with UA levels above the median value (≥ 7.7 mg/dl) exhibited higher mortality rates (21.1 vs. 37.9%; p < 0.001). In multivariable analysis, after adjusting for recognized prognostic factors and potential confounders, UA ≥ 7.7 mg/dl and per change in 1 mg/dl of UA was associated with an increased risk of mortality (HR 1.45, CI 95% = 1.03–2.44; p = 0.03 and HR 1.08, CI 95% = 1.01–1.15; p = 0.03, respectively).ConclusionUA serum levels is an independent predictor of all-cause mortality in an unselected patients admitted with AHF.     

Mortalidad a corto y largo plazo de pacientes con indicación quirúrgica no intervenidos en el curso de la endocarditis infecciosa izquierda

Introduction and objectivesIn infective endocarditis (IE), decisions on surgical interventions are challenging and a high percentage of patients with surgical indication do not undergo these procedures. This study aimed to evaluate the short- and long-term prognosis of patients with surgical indication, comparing those who underwent surgery with those who did not.MethodsWe included 271 patients with left-sided IE treated at our institution from 2003 to 2018 and with an indication for surgery. There were 83 (31%) surgery-indicated not undergoing surgery patients with left-sided infective endocarditis (SINUS-LSIE). The primary outcome was all-cause death by day 60 and the secondary outcome was all-cause death from day 61 to 3 years of follow-up. Multivariable Cox regression and propensity score matching were used for the analysis.ResultsAt the 60-day follow-up, 40 (21.3%) surgically-treated patients and 53 (63.9%) SINUS-LSIE patients died (P < .001). Risk of 60-day mortality was higher in SINUS-LSIE patients (HR, 3.59; 95%CI, 2.16-5.96; P < .001). Other independent predictors of the primary endpoint were unknown etiology, heart failure, atrioventricular block, and shock. From day 61 to the 3-year follow-up, there were no significant differences in the risk of death between surgically-treated and SINUS-LSIE patients (HR, 1.89; 95%CI, 0.68-5.19; P = .220). Results were consistent after propensity score matching. Independent variables associated with the secondary endpoint were previous IE, diabetes mellitus, and Charlson index.ConclusionsTwo-thirds of SINUS-LSIE patients died within 60 days. Among survivors, the long-term mortality depends more on host conditions than on the treatment received during admission.Full English text available from:www.revespcardiol.org/en     

Acute kidney injury in hospitalized patients with COVID-19: A Portuguese cohort

IntroductionThe incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients ranges from 0.5% to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19.MethodsWe conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.ResultsIn this cohort of COVID-19 patients, 55.2% developed AKI (n = 106). The majority of AKI patients had persistent AKI (n = 64, 60.4%). Overall, in-hospital mortality was 18.2% (n = 35) and was higher in AKI patients (28.3% vs. 5.9%, p < 0.001, unadjusted OR 6.03 (2.22–16.37), p < 0.001). In this multivariate analysis, older age (adjusted OR 1.07 (95% CI 1.02–1.11), p = 0.004), lower Hb level (adjusted OR 0.78 (95% CI 0.60–0.98), p = 0.035), duration of AKI (adjusted OR 7.34 for persistent AKI (95% CI 2.37–22.72), p = 0.001) and severity of AKI (adjusted OR 2.65 per increase in KDIGO stage (95% CI 1.32–5.33), p = 0.006) were independent predictors of mortality.ConclusionAKI was frequent in hospitalized patients with COVID-19. Persistent AKI and higher severity of AKI were independent predictors of in-hospital mortality.     

A study of diabetes complications in an endogamous population: An emerging public health burden

AimThe aims of this study were to determine the prevalence of diabetic complications namely neuropathy, nephropathy, and retinopathy among Qatari's DM patients; and to find associations between these complications and socio-demographic and clinical characteristics in a highly consanguineous population.DesignIt is an observational cohort study.SettingThe survey was carried out at the Hamad General Hospital and Primary Health Care (PHC) centers in the State of Qatar.SubjectsThe study was conducted from May 2011 to January 2013 among Qatari nationals above 20 years of age. Of the 2346 registered with diagnosed diabetes attending Hamad General Hospital and PHC centers, 1633 (69.3%) agreed and gave their consent to take part in this study.MethodsQuestionnaire included socio-demographic variables, body mass index (BMI), consanguinity, lifestyle habits, family history of diabetes, blood pressure and development of diabetes complications such as retinopathy, nephropathy, and neuropathy were collected at regular intervals throughout the follow-up. Univariate and multivariate statistical analysis were performed.ResultsOut of 1633 diabetic patients, 842 (51.6%) were males. The prevalence of diabetic nephropathy 12.4% and retinopathy was 12.5% followed by neuropathy 9.5% among diabetic population. The proportion of diabetic neuropathy and nephropathy were significantly higher among diabetic patients with age 60 years and above as compared to younger age groups (p = 0.010). Nephropathy was significantly higher among male diabetic (p = 0.014) and smokers (p < 0.001) while diabetic neuropathy was more common among diabetic hypertensive patients (p = 0.028). Multivariate logistic regression showed that Age (p = 0.025), being male (p = 0.045), and having high blood pressure (p = 0.006) were significant predictors of diabetic neuropathy. For diabetic retinopathy, family history of DM (p < 0.001), consanguinity (p = 0.010), having high blood pressure (p = 0.042) and physical activity (p < 0.001) were significant predictors of diabetic retinopathy. Meanwhile, for diabetic nephropathy, age (p < 0.001), smoking (p = 0.045), physical activity (p < 0.001) hypertension (p < 0.001) and gender (p = 0.012) were the significant predictors.ConclusionDiabetes exerts a significant burden in Qatar, and this is expected to increase. Many diabetic patients face significant challenges accessing diagnosis and treatment, which contributes to the high morbidity and mortality and prevalence of complications observed. The significant interactions between diabetes and associated complications highlight the need and opportunity for health planners to develop integrated responses to communicable and non-communicable diseases.     

Does the preoperative mild renal dysfunction effect mortality and morbidity following valve cardiac surgery?

AimsThe objective of this study was to investigate the effect of preoperative mild renal dysfunction (RD), not requiring dialysis, on mortality and morbidity after valve cardiac surgery (VCS).PopulationWe studied 340 consecutive patients (2008–2012), who underwent VCS with or without coronary artery bypass graft (CABG).MethodsPreoperative RD was calculated with the abbreviated Modification of Diet in Renal Disease formula and was defined as a glomerular filtration rate <60 ml/min/1.73 m². Logistic regression analysis was used to assess the effect of preoperative renal dysfunction (RD) on operative and adverse outcomes.Results80 patients (30%) had preoperative mild RD. Patients with preoperative RD were older, had a higher rate of preoperative anemia (43% vs. 25%, p < 0.001), and more comorbidities. Patients with preoperative RD had worse outcomes with more reoperation (6.8% vs. 2.3%, p < 0.001).ConclusionPreoperative RD was significantly and independently associated with more red blood cell transfusions and longer hospital stay (median 9 vs. 8 days, p < 0.001). Mortality was similar in both groups (3.4% vs. 2.3%, p = 0.43). Preoperative mild RD in patients undergoing cardiac valve surgery is an independent marker of postoperative morbidity.     

In infectious endocarditis patients mortality is highly related to kidney function at time of diagnosis: A prospective observational cohort study of 231 cases

BackgroundInfective endocarditis is a serious disease with a high mortality even with optimal treatment and care. A number of complicating conditions are known to be of importance for the outcome. But only few data are available in IE patients on the independent prognostic value of kidney function at the time of admittance.MethodsIn a prospective observational cohort study data from 235 consecutive IE patients were collected at 2 tertiary heart centres in Copenhagen. Kidney function was evaluated as Estimated Endogenous Creatinine Clearance (EECC) calculated at the time of admission. Patients were divided into 4 groups according to their EECC: 1) > 90 ml/min, 2) 60–90 ml/min, 3) 30–60 ml/min and 4) < 30 ml/min. Mortality statistical analysis was then applied.Results>Gender: 70.2% male, mean age: 61.3 ± SD 15.0. The most common pathogens were streptococcus species (32.9%) and Staphylococcus aureus (21.8%). Mean follow-up time was 453 days (SD 350). A total number of 76 patients died (32%), with an in-hospital mortality of 14%, and a post discharge mortality of 18%. In 64.9% EECC was decreased at time of admission, and a highly significant relationship between EECC and mortality was demonstrated, P < 0.001. For every decrease of 10 ml/min in EECC we found an increase in Hazard Ratio for mortality of 23.1% (CI 13.2–33.8), P < 0.001.ConclusionDecreased kidney function is prevalent in patients with endocarditis. Calculated EECC at the time of admission is easily obtained in all IE patients and has a high and independent predictive prognostic value for mortality.     

Predictors of mortality within three months in the patients with malignant pleural effusion

BackgroundMalignant pleural effusion (MPE) has a limited life expectancy (3–12 months). We investigated the predictors of the early mortality (EM) within three months.MethodsThe patients were retrospectively grouped according to the death within three months (Group I) and survival more than three months (Group II). Demographical, clinical, and biochemical parameters in the fluid were analysed to determine their effects on the EM. The 30-day response rate of talc pleurodesis was investigated.ResultsThe study included 85 patients (Group I/Group II = 40/45). The patients in Group I died within a median of 28 days. Twenty-six patients in Group II died in a median of 205, but 19 were still alive (median 200 days). The median survival was longer in renal cell, colorectal, breast, liver, ovarian and oropharynx carcinoma, and mesothelioma. Sixty-two patients (63%) underwent talc pleurodesis, which prevented the fluid reaccumulation (p = 0.04). The significant factors of the EM in the univariate analysis were the presence of high-risk tumors (lung, stomach, soft tissue, bladder, esophagus, prostate, cervix, and lymphoma), the low Karnofsky performance score (KPS) (p < 0.0001), the low pH value of the fluid (p = 0.05), and the low concentration of glucose (p = 0.01), total protein (p < 0.0001), and albumin (p < 0.0001) in the fluid. According to the multivariate analysis high-risk tumors (p = 0.03), a lower KPS (p < 0.001), and glucose value (p = 0.04) were the predictors of the EM.ConclusionTalc pleurodesis prevents the fluid reaccumulation. High-risk tumors, a poor performance status, and lower pleural fluid glucose concentration are predictors of the EM within three months in the patients with a MPE.     

C-reactive protein (CRP): An important diagnostic and prognostic tool in nursing-home-associated pneumonia

Pneumonia is the second most common infection in long term care (LTC) residents and is a leading cause of death from infection in those groups of patients. Atypical presentations and fewer presenting signs and symptoms in older patients complicate diagnosis and delay initiation of adequate treatment. The aim of this study was to compare laboratory CRP levels to pneumonia severity scores, in prediction of short-term death from pneumonia. Diagnosis of pneumonia was performed according to the criteria of McGeer for the identification of pneumonia at an LTC facility. The severities of pneumonia and mortality prediction were assessed by three indices: PSI (pneumonia severity index), Missouri study index and the nursing home associated pneumonia (NHAP) severity index. A strong positive correlation was found between CRP levels and PSI (r = 0.445, p < 0.001), Missouri study index (r = 0.315, p < 0.001) and NHAP severity index (r = 0.246, p = 0.002). The initial values of CRP were significantly higher in patients with short term mortality and positively correlated with rate of death (r = 0.493, p < 0.001). By multivariate regression analysis, the variables that were independently and significantly associated with the rate of death included presence and duration of fever, respiratory rate, serum CRP and albumin levels, lymphocyte count, number of comorbid diseases, CHF, and DM (the R² was 0.711 and 0.685 when adjusted). Because presentation of nursing home acquired pneumonia is not specific, it is suggested that CRP should be performed in every patient with a suspicion of pneumonia.     

Endocarditis infecciosa después de TAVI: aportaciones de la experiencia en un único centro sobre la incidencia y los factores asociados

IntroductionInfective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is an emerging complication. There are incomplete and disparate data on its incidence. We present the experience of a single-centre of incidence, mortality and associated factors of IE after TAVI.MethodsA retrospective observational study of IE cases in people who received a TAVI, between 06/01/2009 and 11/01/2017, in a university hospital, during a median follow-up period of 15.3 months (interquartile range [IQR] 9.1-36.2). Incidence, clinical, microbiological and prognostic data, and factors associated with IE after TAVI were analysed.ResultsEleven patients with IE of 200 TAVI were detected. Global incidence: 5.5% (2.77 cases per 100 patient-year). The median of days from TAVI to IE was 112 (IQR 36-578), the in-hospital mortality rate was 36.4%, and the one-year mortality rate was 54.5%. All the organisms identified were gram-positive (4 Enterococcus faecalis, 3 coagulase-negative Staphylococcus). The patients with IE after TAVI were significantly younger (median 78 years, IQR 73-80, versus 82 years, IQR 79-84, P = .002), they had a higher EuroSCORE (5.1 ± 2.4 versus 3.2 ± 1.2, P < .001), and they more frequently had a history of neoplasia (18.2% versus 4.2%, P < .03)ConclusionsIn our area, IE after TAVI has an incidence greater than that described in multicentre series, this is in line with the trend published in the literature. It leads to high mortality and is associated with a worse baseline clinical situation.     

Administration of low molecular weight and unfractionated heparin during percutaneous coronary intervention

This systematic review with meta-analysis sought to determine the efficacy and safety of unfractionated heparin (UFH) and low molecular weight heparin (LMWH) on clinical outcomes following percutaneous coronary intervention. Medline, Embase, Elsevier, and web of knowledge as well as Google scholar literature were used for selecting appropriate studies with randomized controlled design. After screening 445 studies, a total of 23 trials (including a total of 43,912 patients) were identified that reported outcomes. Pooled analysis revealed that LMWH compared to UFH could significantly increase thrombolysis in myocardial infarction grade 3 flow (p < 0.001), which was associated with similar target vessel revascularization (p = 0.6), similar incidence of stroke (p = 0.7), and significantly lower incidence of re-myocardial infarction (p < 0.001), major bleeding (p = 0.02) and mortality (p < 0.001). Overall, LMWH was shown to be a useful type of heparin for patients with MI undergoing PCI, due to its higher efficacy and lower rate of complication compared to UFH. It is also associated with increased myocardial perfusion, decreased major hemorrhage, and mortality.     

Determinants of adherence to oral hygiene prophylaxis guidelines in patients with previous infective endocarditis

BackgroundInfective endocarditis (IE) is characterized by low incidence but high mortality. Patients with a history of IE are at highest risk. Adherence to prophylaxis recommendations is poor. We sought to identify determinants of adherence to oral hygiene guidelines on IE prophylaxis in patients with a history of IE.MethodsUsing data from the cross-sectional, single-centre POST-IMAGE study, we analysed demographic, medical and psychosocial factors. We defined patients as adherent to prophylaxis if they declared going to the dentist at least annually and brushing their teeth at least twice a day. Depression, cognitive status and quality of life were assessed using validated scales.ResultsOf 100 patients enrolled, 98 completed the self-questionnaires. Among these, 40 (40.8%) were categorized as adherent to prophylaxis guidelines, and were less likely to be smokers (5.1% vs. 25.0%; P = 0.02) or have symptoms of depression (36.6% vs. 70.8%; P < 0.01) or cognitive decline (0% vs. 15.5%; P = 0.05). Conversely, they had higher rates of: valvular surgery since the index IE episode (17.5% vs. 3.4%; P = 0.04), searching for information on IE (61.1% vs. 46.3%, P = 0.05), and considering themselves as adherent to IE prophylaxis (58.3% vs. 32.1%; P = 0.03). Tooth brushing, dental visits and antibiotic prophylaxis were correctly identified as measures to prevent IE recurrence in 87.7%, 90.8% and 92.8% of patients, respectively, and did not differ according to adherence to oral hygiene guidelines.ConclusionsSelf-reported adherence to secondary oral hygiene guidelines on IE prophylaxis is low. Adherence is unrelated to most patient characteristics, but to depression and cognitive impairment. Poor adherence appears related more to a lack of implementation rather than insufficient knowledge. Assessment of depression may be considered in patients with IE.     

Incidence and predictors of rebleeding after band ligation of oesophageal varices

Background and study aimsVariceal bleeding is a severe complication in patients with portal hypertension. Early rebleeding occurs frequently in the first few weeks after band ligation, and the mortality associated with each bleeding episode ranges from 30% to 50%. Our aims were to study the rate of early rebleeding oesophageal varices after band ligation in the Sohag University Hospital, Egypt, and to assess different clinical, biochemical, ultrasonographic, and endoscopic parameters that may predict the risk factors of rebleeding.Patients and methodsIn the period from December 2011 to December 2012, we performed endoscopic variceal ligation (EVL) for 146 cirrhotic patients (105 male and 41 female) with a mean age of 51.77 ± 10.47 years; the patients were divided into rebleeding and non-rebleeding groups. Complete history taking, clinical examination, laboratory investigations, abdominal ultrasound (US), and upper gastrointestinal (GI) endoscopy were performed for all patients.ResultsThe incidence of early rebleeding after EVL was 20.54%, and it was significantly associated with male gender (p = 0.013), older age (p = 0.009), infection with spontaneous bacterial peritonitis (SBP) (p < 0.0007), reduced liver size (p = 0.017), a coarser echo pattern (p = 0.03), the presence of hepatic focal lesions (p < 0.001), splenomegaly (p = 0.02), the presence of portosystemic collaterals (p = 0.006), a low haemoglobin (HB) level (p < 0.0001), prothrombin concentration (p = 0.017), high aspartate aminotransferase (AST) level (p = 0.01), Child–Pugh B and C (p = 0.02, 0.003), large oesophageal varices F3 in the two endoscopies (p = 0.002; p < 0.0001), varices extending to the superior third Ls (p < 0.001), and the presence of massive red colour signs (RC+++) (p < 0.0001). By multivariate analysis, SBP and low HB level were found to be independent predictors of rebleeding.ConclusionThe following conclusions were drawn from this study: (1) The incidence of rebleeding after EVL in our centre is about 20%. (2) Early rebleeding after EVL is affected by many clinical, laboratory, ultrasonographic, and endoscopic parameters. The most prominent of them are SBP, splenomegaly, the presence of collaterals, anaemia, more decompensated cirrhosis, and the presence of large varices with red signs. (3) SBP and low HB level were found to be independent predictors of rebleeding.     

Serum melatonin levels during the first seven days of severe sepsis diagnosis are associated with sepsis severity and mortality

Objective

Higher serum melatonin levels have previously been found in patients with severe sepsis who died within 30 days of diagnosis than in survivors. The objective of our study were to determine whether serum melatonin levels during the first seven days of severe sepsis diagnosis could be associated with sepsis severity and mortality.

Facteurs prédictifs de long séjour en réanimation après chirurgie cardiaque programmée de l’adulte : étude rétrospective monocentrique sur 5 ans et demi

AimThe aim of our study was to identify predictors for prolonged ICU stay following elective adult cardiac surgery under cardiopulmonary bypass.Patients and methodsA retrospective study was conducted during 5 years and a half period. Were included, patients age ≥ 18 years old, underwent elective cardiac surgery under cardiopulmonary bypass. Patients who died within 48 hours of surgery were excluded. Prolonged ICU stay was defined as stay in the ICU for 48 hours or more.ResultsDuring the review period, 610 patients were included. One hundred and sixty-four patients have required a prolonged ICU stay (26.9 %). In multivariate analysis, 5 predictors were identified: ejection fraction < 30 % (OR 19.991, IC 95 % [1.382–289.1], P = 0.028], pulmonary hypertension (OR 2.293, IC 95 % [1.058–4.973], P = 0.036), prolonged ventilation (≥ 12 hours) (OR 4.026, IC 95 % [2.407–6.733], P < 0.001). Number of blood units transfused (OR 1.568, IC 95 % [1.073–2.291], and postoperative acute renal failure (OR 2.620, IC 95 % [1.026–6.690], P = 0.044]. Prolonged ICU stay is significantly associated with prolonged hospital stay (17 days vs 13 days ; P < 0.001) and higher in hospital mortality (22 % vs. 3 %, P < 0.001).ConclusionThe identification of these patients at risk of prolonged ICU stay is crucial. It will aid to plan prophylactic measures to optimize their support.