Abstract Context Since the development of palliative care in the 1980s, “do not resuscitate” (DNR) has been promoted worldwide to avoid unnecessary resuscitation in terminally ill cancer patients. ...Objectives This study aimed to evaluate the effect of a palliative care consultation service (PCCS) on DNR designation and to identify a subgroup of patients who would potentially benefit from care by the PCCS with respect to DNR designation. Methods In total, 2995 terminally ill cancer patients (with a predicted life expectancy of less than six months by clinician estimate) who received care by the PCCS between January 2006 and December 2010 at a single medical center in Taiwan were selected. Among these, the characteristics of 2020 (67.4%) patients who were not designated as DNR at the beginning of care by the PCCS were retrospectively analyzed to identify variables pertinent to DNR designation. Results A total of 1301 (64%) of 2020 patients were designated as DNR at the end of care by the PCCS. Male gender and primary liver cancer were characteristics more predominantly found among DNR-designated patients who also had worse performance status, higher prevalence of physical distress, and shorter intervals from palliative care referral to death than did patients without DNR designation. On univariate analysis, a higher probability of DNR designation was associated with male gender, duration of care by the PCCS of more than 14 days, patients' prognostic awareness, family's diagnostic and prognostic awareness, and high Palliative Prognostic Index (PPI) scores. On multivariate analysis, duration of care by the PCCS, patients' prognostic awareness, family's diagnostic and prognostic awareness, and a high PPI score constituted independent variables predicting DNR-designated patients at the end of care by the PCCS. Conclusion DNR designation was late in terminally ill cancer patients. DNR-designated cancer patient indicators were high PPI scores, patients' prognostic awareness, family's diagnostic and prognostic awareness, and longer durations of care by the PCCS.
Background Extracorporeal membrane oxygenation (ECMO) can be used as a salvage therapy, but the effectiveness is controversial. The aim of this study was to investigate the predictors of mortality ...and the influence of organ dysfunction scores in severe acute respiratory distress syndrome (ARDS) patients treated with ECMO. Methods The records of adult severe ARDS patients receiving ECMO support from May 2006 to December 2011 at Chang Gung Memorial Hospital were retrospectively analyzed. Results The records of 65 patients with severe ARDS who received venovenous ECMO were analyzed. The hospital survival rate was 47.7%. Survivors were younger than nonsurvivors (41.4 ± 15.4 versus 54.1 ± 16.9 years, respectively; p = 0.002) and had shorter duration of mechanical ventilation before ECMO (52.7 ± 51.1 versus 112.1 ± 101.0 hours, respectively; p = 0.01). Before ECMO, Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, and Multiple Organ Dysfunction scores were significantly lower for survivors than for nonsurvivors. Mortality rate increased with rising predictive score. During 7 days of ECMO use, organ dysfunction scores were significantly lower for survivors than nonsurvivors. Conclusions Severe ARDS patients who are younger, have shorter duration of mechanical ventilation, and lower organ dysfunction scores before ECMO initiation have more favorable survival outcome. Early application of ECMO, especially if predictive score is below 2, may improve survival. Organ dysfunction scores before and during ECMO support are correlated with survival.
Abstract Objective The study aims to assess if electrocardiographic (ECG) abnormalities could predict the development of neurogenic pulmonary edema (NPE) within 24 hours in cases of spontaneous ...subarachnoid hemorrhage (SAH). Methods We studied prospectively a cohort of 269 adult patients with nontraumatic SAH in an emergency department of a university-affiliated medical center. A 12-lead ECG was taken for these patients. The patients were stratified into NPE and non-NPE based on serially clinical and radiologic findings. The ECG abnormalities were compared between these 2 groups of patients. Results Compared with the non-NPE (n = 229), the NPE (n = 40) had significantly higher World Federation of Neurological Surgeons class ( P < .001), higher Hunt-Hess scale ( P < .001), and higher prevalence of diabetes mellitus ( P = .033). In addition, the percentage of ECG morphological abnormality was significantly higher in NPE, in which nonspecific ST- or T-wave changes (NSSTTCs) are significantly higher. Multiple logistic regression model identified World Federation of Neurological Surgeons class (95% confidence interval CI, 2.6-13.3; P < .001), abnormal Q or QS wave (95% CI, 1.1-9.1; P = .038), and NSSTTCs (95% CI, 1.2-7.5; P = .016) as the significant variables associated with NPE. Conclusions Electrocardiographic abnormalities, especially abnormal Q or QS wave and NSSTTCs, may predict the development of NPE within 24 hours in adult patients with spontaneous SAH.
Background Fluid overload is a common phenomenon in patients in a late stage of chronic kidney disease (CKD). However, little is known about whether fluid overload is related to kidney disease ...progression in patients with CKD. Accordingly, the aim of the study was to assess the association of the severity of fluid status and kidney disease progression in an advanced CKD cohort. Study Design Prospective observational cohort study. Setting & Participants This cohort study enrolled 472 non−dialysis-dependent patients with CKD stages 4-5 who were in an integrated CKD care program from January 2011 to December 2011 and followed up until December 2012 or initiation of renal replacement therapy (RRT). Predictors Tertile of fluid overload, with cutoff values at 0.6 and 1.6 L. Outcomes RRT, rapid estimated glomerular filtration rate (eGFR) decline (faster than 3 mL/min/1.73 m2 per year), and change in eGFR. Measurements The severity of fluid overload was measured by a bioimpedance spectroscopy method. eGFR was computed using the 4-variable MDRD (Modification of Diet in Renal Disease) Study equation. Results During a median 17.3-month follow-up, 71 (15.0%) patients initiated RRT and 187 (39.6%) experienced rapid eGFR decline. The severity of fluid overload was associated with increased risk of RRT (tertile 3 vs tertile 1: adjusted HR, 3.16 95% CI, 1.33-7.50). Fluid overload value was associated with increased risk of rapid eGFR decline (tertile 3 vs tertile 1: adjusted OR, 4.68 95% CI, 2.30-9.52). Furthermore, the linear mixed-effects model showed that the reduction in eGFR over time was faster in tertile 3 than in tertile 1 ( P = 0.02). Limitations The effect of fluid volume variation over time must be considered. Conclusions Fluid overload is an independent risk factor associated with initiation of RRT and rapid eGFR decline in patients with advanced CKD.
Abstract Objectives This study sought to determine predictors for successful endovascular treatment in patients with chronic carotid artery occlusion (CAO). Background Endovascular recanalization in ...patients with chronic CAO has been reported to be feasible, but technically challenging. Methods Endovascular attempts in 138 consecutive chronic CAO patients with impaired ipsilateral hemisphere perfusion were reviewed. We analyzed potential variables including epidemiology, symptomatology, angiographic morphology, and interventional techniques in relation to the technical success. Results The technical success rate was 61.6%. Multivariate analysis showed absence of prior neurologic event (odds ratio OR: 0.27; 95% confidence interval CI: 0.10 to 0.76), nontapered stump (OR: 0.18; 95% CI: 0.05 to 0.67), distal internal carotid artery (ICA) reconstitution via contralateral injection (OR: 0.19; 95% CI: 0.05 to 0.75), and distal ICA reconstitution at communicating or ophthalmic segments (OR:0.12; 95% CI: 0.04 to 0.36) to be independent factors associated with lower technical success. Point scores were assigned proportional to model coefficients, and technical success rates were >80% and <40% in patients with scores of ≤1 and ≥4, respectively. The c-indexes for this score system in predicting technical success was 0.820 (95% CI: 0.748 to 0.892; p < 0.001) with a sensitivity of 84.7% and a specificity of 67.9%. Conclusions Absence of prior neurologic event, nontapered stump, distal ICA reconstitution via contralateral injection, and distal ICA reconstitution at communicating or ophthalmic segments were identified as independent negative predictors for technical success in endovascular recanalization for CAO.
Background Depression is related to morbidity and mortality in patients with kidney failure treated by dialysis, but its influence on patients with earlier stages of chronic kidney disease (CKD) is ...uncertain. This study investigates the association of depressive symptoms with clinical outcomes in patients with CKD not requiring dialysis. Study Design Prospective observational cohort study. Setting & Participants 568 participants with CKD not requiring maintenance dialysis were recruited consecutively at a tertiary hospital in Southern Taiwan and followed up for 4 years. Predictors Baseline status of depressive symptoms. Outcomes The primary outcome is a composite of progression to end-stage renal disease (ESRD), defined as requiring maintenance dialysis treatment, or all-cause mortality; and secondary outcome was first hospitalization. Measurements Depressive symptoms were assessed by Beck Depression Inventory. Estimated glomerular filtration rate (eGFR) was computed using the 4-variable MDRD (Modification of Diet in Renal Disease) Study equation. Results 428 participants completed the questionnaires and 160 (37%) had depressive symptoms. During a mean follow-up of 25.2 ± 11.9 months, 136 participants (32%) reached the primary outcome (119 reached ESRD and 17 died) and 110 participants (26%) were hospitalized. High depressive symptoms increased the risk of progression to ESRD or death (HR, 1.66; 95% CI, 1.14-2.44) and first hospitalization (HR, 1.59; 95% CI, 1.03-2.47). Participants with high depressive symptoms had more rapid GFR decrease (eGFR slopes of −2.3 25th-75th percentile, −5.3 to −0.4 vs −1.2 25th-75th percentile, −3.5 to 0.3 mL/min/1.73 m2 per year; P = 0.001) and initial dialysis treatment at a higher eGFR (OR for initiation of dialysis at eGFR >5 mL/min/1.73 m2 , 4.45; 95% CI, 1.44-13.78). Limitations A single-center study of Taiwanese, Beck Depression Inventory evaluates only depressive symptom burden. Conclusions Depressive symptoms in CKD are independent predictors of adverse clinical outcomes, including faster eGFR decrease, dialysis therapy initiation, death, or hospitalization. Depression should be evaluated early and treated in patients with CKD.
Purpose Tube thoracostomy is a common and generally safe procedure. However, potential hazards can occur during placement of the chest tube. Inasmuch as unexpected injuries may arise from tube ...thoracostomy, we propose a novel video-guided method. Description We used an independent complementary metal oxide semiconductor image sensor with a processing chip to obtain a front view image of the chest cavity. The device is connected to an aluminum shaft with four small light-emitting diode crystals in the tip, and a detachable small monitor with a battery inside. The apparatus is small and can be used to direct vision-guided tools in tube thoracostomy. Evaluation We performed video-guided tube thoracostomy in 6 patients with pleural adhesions. All patients experienced good tolerance to the procedure and had no immediate adverse events. The thoracostomies were performed by a single surgeon with good acceptability, and each procedure was completed in less than 10 minutes. Conclusions In some cases of pleural adhesion, the video-guided thoracostomy may be a safer alternative to non–image guided tube thoracostomy.
Objective To evaluate whether very early treatment in our patients would result in better clinical outcomes and to compare these data with other infantile-onset Pompe disease (IOPD) cohort studies. ...Methods In this nationwide program, 669 797 newborns were screened for Pompe disease. We diagnosed IOPD in 14 of these newborns, and all were treated and followed in our hospital. Results After 2010, the mean age at first enzyme-replacement therapy (ERT) was 11.92 days. Our patients had better biological, physical, and developmental outcomes and lower anti-rh acid α-glucosidase antibodies after 2 years of treatment, even compared with one group that began ERT just 10 days later than our cohort. No patient had a hearing disorder or abnormal vision. The mean age for independent walking was 11.6 ± 1.3 months, the same age as normal children. Conclusions ERT for patients with IOPD should be initiated as early as possible before irreversible damage occurs. Our results indicate that early identification of patients with IOPD allows for the very early initiation of ERT. Starting ERT even a few days earlier may lead to better patient outcomes.
Abstract Objective Biphasic defibrillation is more effective than monophasic one in controlled in-hospital conditions. The present review evaluated the performance of both waveforms in the ...defibrillation of patients of out-of-hospital cardiac arrest (OHCA) with initial ventricular fibrillation (Vf) rhythm under the context of current recommendations for cardiopulmonary resuscitation. Methods From inception to June 2012, Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched systemically for randomized controlled trials (RCTs) and observational cohort studies that compared the effects of biphasic and monophasic shocks on Vf termination, return of spontaneous circulation (ROSC), and survival to hospital discharge in OHCA patients with initial Vf rhythm. No restrictions were applied regarding language, population, or publication year. Results Four RCTs including 572 patients were identified from 131 potentially relevant references for meta-analysis. The synthesis of these RCTs yielded fixed-effect pooled risk ratios (RRs) for biphasic and monophasic waveforms on Vf termination survival to hospital discharge (RR, 1.14; 95% CI, 0.84-1.54). Conclusion Biphasic waveforms did not seem superior to monophasic ones with respect to Vf termination, ROSC, or survival to hospital discharge in OHCA patients with initial Vf rhythm under the context of current guidelines. However, most trials were conducted in accordance with previous guidelines for cardiopulmonary resuscitation. Therefore, further trials are needed to clarify this issue.
Objectives: Recently, molecular medicine targeting Folate Receptor Alpha (FOLR1), which mediates intracellular folate uptake and tumor cell proliferation, has been identified in several malignancies. ...However, the association between FOLR1 expression and rectal cancer remains unclear. Methods: Immunostaining of FOLR1 was performed on biopsy specimens from 172 rectal cancer patients undergoing preoperative chemoradiotherapy (CRT). FOLR1 expression was measured and divided into low (0+-2+) or high (3+-4+) level. Correlations between FOLR1 status and clinicopathologic features, tumor regression grade, disease-specific survival (DSS), local recurrence-free survival, and metastasis-free survival (MeFS) were analyzed, retrospectively. Results: High FOLR1 expression was significantly associated with advanced post-treatment tumor and nodal status (T3-4; N1-2, P = .001), vascular invasion (P = .042), perineural invasion (P = .012), and poor regression change after CRT (P = .001). In uni- and multi-variable survival analysis, FOLR1 overexpression remained a significant predictor of lower DSS (hazard ratio HR, 2.328; 95% confidence interval CI, 1.014-5.344; P = .046) and MeFS (HR, 2.177; 95% CI, 1.000-1.1286; P = .050). Conclusion: These results indicate that high FOLR1 status is associated with aggressive tumor behavior, poor response to CRT, and worse survival. Therefore, FOLR1 expression at initial biopsy may be useful in predicting outcomes and also be a target for the exploration of FOLR1-based therapeutic agents.
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