Background Extracorporeal membrane oxygenation (ECMO) has been utilized for patients in critical condition, such as those with life-threatening respiratory failure or postcardiotomy cardiogenic ...shock. This study analyzed the outcomes of patients treated with ECMO and identified the relationship between prognosis and the Acute Kidney Injury Network (AKIN) scores obtained at pre-ECMO support (AKIN 0-hour ); and at post-ECMO support 24 hours (AKIN 24-hour ) and 48 hours (AKIN 48-hour ). Methods This study reviewed the medical records of 102 critically ill patients on ECMO support at a specialized intensive care unit at a tertiary care university hospital between March 2002 and January 2008. Demographic, clinical, and laboratory variables were retrospectively collected as survival predicators. Results The overall mortality rate was 57.8%. The most common condition requiring ECMO support was cardiogenic shock. Goodness-of-fit was good for AKIN 0-hour , AKIN 24-hour , and AKIN 48-hour criteria. The AKIN 0-hour , AKIN 24-hour , and AKIN 48-hour scoring systems also had excellent areas under the receiver operating characteristic curve (0.804 ± 0.046, 0.811 ± 0.045, and 0.858 ± 0.040, respectively). Furthermore, multiple logistic regression analysis indicated that AKIN 48-hour , age, and Glasgow Coma Scale score on the first day of intensive care unit admission were independent risk factors for hospital mortality. Finally, cumulative survival rates at 6-month follow-up after hospital discharge differed significantly ( p < 0.05) for AKIN 48-hour stage 0 versus AKIN 48-hour stages 1, 2, and 3; and AKIN 48-hour stage 1 and 2 versus AKIN 48-hour stage 3. Conclusions During ECMO support, the AKIN 48-hour scoring system proved to be a reproducible evaluation tool with excellent prognostic abilities for these patients.
Background Extracorporeal membrane oxygenation (ECMO) has been utilized for patients in critical condition, including life-threatening respiratory failure and postcardiotomy cardiogenic shock. This ...study analyzed the outcomes of patients with acute respiratory distress syndrome (ARDS) treated by ECMO and identified the relationship between prognosis and urine output (UO) obtained on the first day of ECMO support. Methods This study reviewed the medical records of 81 ARDS patients after ECMO support on a specialized cardiovascular surgery intensive care unit of a tertiary care university hospital between May 2006 and December 2011. Demographic, clinical, and laboratory variables were retrospectively collected as survival predictors. Results The overall mortality rate was 55.5%. A multiple logistic regression analysis indicated that the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, mean arterial pressure, platelet count, and UO on day 1 of ECMO support were independent risk factors for hospital mortality. By using the areas under the receiver operating characteristic (AUROC) curve, UO obtained on the first day of ECMO support demonstrated good discriminative power (AUROC 0.754 ± 0.056, p < 0.001). Urine output had the best discriminative power, the best Youden index, and the highest overall correctness of prediction. Cumulative survival rates at the 6-month follow-up differed significantly ( p < 0.001) for UO 1,432 mL or greater on day 1 of ECMO support versus those with UO less than 1,432 mL on day 1 of ECMO support. Conclusions In ARDS patients receiving ECMO support, UO obtained on the first day of ECMO support showed good prognostic ability in predicting hospital mortality.
Abstract Objective Extracorporeal membrane oxygenation (ECMO) is a widely used technique for treating postcardiotomy cardiogenic shock (PCS); however, no study has compared the long-term outcomes of ...patients who receive ECMO support for PCS with those of the general population post cardiac surgery. Methods A total of 1141 patients who received ECMO after cardiac surgery between 2000 and 2011 were identified by using the Taiwan National Health Insurance Research Database. For each patient, we matched 5 non-ECMO patients who had undergone cardiac surgery by using propensity scores calculated for age, sex, 12 comorbid diseases, Charlson score, hospital level, type of cardiac surgery, and year of index hospitalization. The outcomes included all-cause mortality, readmission for any cause, and medical expenditure. Results The incidence of ECMO use after cardiac surgery in Taiwan was 1.91%. The ECMO group had a significantly higher risk of in-hospital mortality than did the non-ECMO group (61.7% vs 6.8%, odds ratio 22.34, 95% confidence interval 19.06-26.18). The risks of all-cause mortality and first readmission for any cause were greater in the ECMO group than that in the control group ( P < .001, P < .001) in the first year, whereas no difference was observed after the first year of follow-up ( P = .209, P = .474). Similar results were observed regarding the medical expenditure of admission after index admission discharge. Conclusions Patients receiving ECMO for PCS had similar outcomes to those of the non-ECMO group after the first year of follow-up despite significantly poor outcomes during the in-hospital course.
Background Acute respiratory distress syndrome (ARDS) is a life-threatening medical condition. Extracorporeal membrane oxygenation (ECMO) is a salvage therapy for patients with ARDS and refractory ...hypoxia. This study compared the characteristics and outcomes of ARDS patients who did or did not receive ECMO matched with Acute Physiology and Chronic Health Evaluation II (APACHE II) score and age. Methods This retrospective, case-control study enrolled patients with ARDS admitted to the intensive care unit of a tertiary referral hospital between January 2007 and December 2012. Overall, 216 patients with ARDS—81 receiving ECMO (ECMO group) and 135 not receiving ECMO (non-ECMO group)—were enrolled in this study. Patients were paired when the difference in their APACHE II scores was within 3 points and their age difference was 3 years. In total, 126 patients could not be matched and were thus excluded. Eventually, of the 90 patients with ARDS enrolled in this study, 45 ECMO group patients were matched with 45 non-ECMO group patients. The demographic data, reasons for intensive care unit admission, and laboratory variables were evaluated. Results The primary etiology of ARDS was infection (72.2%). The APACHE II score and age-matched group receiving ECMO therapy had higher inhospital survival rates. Moreover, the patients receiving ECMO therapy had significantly lower 6-month mortality rates than did the non-ECMO group. Conclusions Patients with ARDS who received ECMO treatment had higher inhospital survival rates than did those with a similar disease severity and at a similar age who did not receive ECMO.
Abstract Background Chronic kidney disease (CKD) is associated with adverse outcomes in patients who undergo coronary artery bypass grafting (CABG). However, the impact of preoperative dialysis ...dependence and duration in CKD patients on outcomes after CABG has limited research. Objectives To evaluate the effect of preoperative dialysis dependence and duration on CABG outcomes in patients with CKD. Methods A total of 33,920 patients without CKD and 2573 patients with CKD, all of whom underwent isolated CABG between 1998 and 2009, were identified using the Taiwan National Health Insurance Research Database. The patients with CKD were divided into non-dialysis ( N = 1167), dialysis < 3 years ( N = 749), and dialysis ≥ 3 years ( N = 657) groups. The primary outcomes were cumulative incidence of all-cause mortality, cardiovascular (CV) death, and myocardial infarction (MI) or repeat revascularization. Results After adjustment of all covariates, a higher all-cause mortality was associated with dialysis ≥ 3 years than with dialysis < 3 years (hazard ratio HR, 1.56; 95% confidence interval CI, 1.35–1.80; P < 0.001) and with non-dialysis (HR, 1.41; 95% CI, 1.20–1.66; P < 0.001) after 2 years of follow-up. Similar results were observed for CV death. In addition, both the dialysis groups had a higher risk of MI or revascularization than the non-dialysis group. Furthermore, subgroup analysis revealed that longer duration was associated with a higher risk of 30-day mortality ( P for linear trend < 0.001). Conclusions Among the CABG recipients, dialysis dependence is associated with a higher incidence of MI or repeat revascularization, and longer dialysis duration is associated with a higher risk of mortality.
Background Acute kidney injury (AKI) is an established indicator of all-cause mortality in a coronary care unit (CCU), and evaluating the risks of renal dysfunction can guide treatment decisions. In ...this study we used the Society of Thoracic Surgeons (STS) score to predict the incidence of AKI in CCU patients who had not undergone coronary artery bypass surgery (CABG) after a cardiac angiogram. Methods The study cohort comprised 126 patients diagnosed with 2 or 3 coronary vessels disease who did not receive CABG during their hospital course. This study was performed in the CCU of a tertiary referral university hospital between September 2012 and August 2013. The STS score was evaluated with adjustment in all patients and the outcomes of the risk of mortality, morbidity, or mortality and renal failure were selected for predicting assessment. Furthermore, the performance of the STS scores was compared with that of other scoring systems. Results A total of 28.5% (36 of 126) of the patients had AKI of varying severity. For predicting AKI, the STS renal failure score was excellent, with areas under the receiver operating characteristic curve of 0.851 ± 0.039, p < 0.001. When compared with other scoring systems, the STS renal failure score demonstrated the highest discriminatory power, the most favorable Youden index, and the highest overall correctness of prediction. Conclusions The STS score is an effective tool for predicting AKI in patients with coronary artery disease who have not undergone CABG. Frequent monitoring of serum creatinine level or early application of AKI biomarkers are warranted for STS renal failure 5.7% or greater.
Epidemiological Study on the Effect of Pre-Hypertension and Family History of Hypertension on Cardiac Autonomic Function Jin-Shang Wu, Feng-Hwa Lu, Yi-Ching Yang, Thy-Sheng Lin, Jia-Jin Chen, ...Chih-Hsing Wu, Ying-Hsiang Huang, Chih-Jen Chang Pre-hypertension and a family history of hypertension (FHH) are the risk factors for hypertension and they might be considered as the beginning of the cardiovascular disease continuum. Our study provides evidence that cardiac autonomic function plays a role in pre-hypertension and that altered autonomic function is already present in subjects with FHH. Implementation of a preventive strategy for pre-hypertensive subjects is getting more important, because successful preventive management might be expected to reduce cardiovascular morbidity and mortality. In the future, intervention studies are needed to clarify the role of autonomic function in the preventive strategy of high blood pressure in subjects with FHH and pre-hypertension.
Abstract Chen CP, Wong AM, Hsu C-C, Tsai W-C, Chang C-N, Lin S-C, Huang Y-C, Chang C-H, Tang SF. Ultrasound as a screening tool for proceeding with caudal epidural injections. Objective To study the ...anatomical structure of the sacral hiatus using ultrasound. Based on the sonographic images of the sacral hiatus, the feasibility of caudal epidural injection can then be assessed. Design Case-controlled study. Setting Rehabilitation outpatient clinic in a tertiary medical center. Participants Patients (N=47; 20 women, 27 men) with low back pain and sciatica who were to receive caudal epidural injection treatments were recruited into this study. Interventions Sonographic images of the sacral hiatus were obtained from all the patients. An ultrasound machine capable of examining musculoskeletal tissues with real-time linear-array ultrasound transducer was used to measure the distance between the anterior wall and posterior wall of the sacral hiatus (diameter of the sacral hiatus) and the distance between bilateral cornua. Main Outcome Measures Diameter of the sacral canal and distance between bilateral cornua measured in millimeters. Results The mean diameter of the sacral canal was measured to be 5.3±2.0mm in our recruited patients. The mean distance between bilateral cornua was measured to be 9.7±1.9mm. Caudal epidural injections failed in 7 patients. In these 7 patients, 4 had very small diameter of the sacral canal (1.6, 1.2, 1.4, and 1.5mm). In 1 man, sonographic images revealed a closed sacral hiatus (no sacral canal diameter can be measured). Two patients revealed flow of fresh blood into the syringe while checking for the escape of cerebrospinal fluid after the needles were inserted into the sacral canal. For safety reasons, steroid injections were not performed in these 2 patients. Conclusions Ultrasound may be used as an effective screening tool for caudal epidural injections. Anatomic variations of the sacral hiatus can be clearly observed using ultrasound. Sonographic images indicating a closed sacral canal and sacral diameters ranging from 1.2 to 1.6mm may suggest a higher failure rate in caudal epidural injection.
Summary Rac GTPase activating protein 1 (RACGAP1) plays a regulatory role in initiation of cytokinesis, control of cell growth and differentiation, and tumor malignancy, making it a potential ...prognostic biomarker. RACGAP1 is present in the nucleus, but a diffuse distribution in the cytoplasm also occurs. The aim of this study was to determine the impact of nuclear and cytoplasmic expression of RACGAP1 on clinical outcome to provide further evidence of a role in colorectal cancer. RACGAP1 expression was analyzed by immunohistochemistry in 166 cancer specimens from primary colorectal cancer patients. The mean follow-up time after surgery was 5.4 years (range, 0.01-13.10 years). The prognostic value of RACGAP1 on overall survival was validated by Kaplan-Meier analysis and Cox regression models. RACGAP1 is expressed in colorectal specimen and is present in both the nucleus and cytoplasm in different amounts. Colorectal cancer patients had opposite prognoses depending on the site of RACGAP1 expression. Patients with high nuclear RACGAP1 expression had poor outcomes, whereas those with high cytoplasmic RACGAP1 expression had favorable prognosis ( P = .003 and P = .001, respectively). Patients with low nuclear but high cytoplasmic RACGAP1 expression had better survival compared with those with other combinations ( P < .001). We suggest that RACGAP1 expression levels in the nucleus and cytoplasm, determined by immunohistochemical staining, predict opposite clinical outcomes and that both could be independent prognostic markers for colorectal cancer.
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