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Parvataneni S, Sarkis Y, Haugh M, Baker B, Tang Q, Nephew LD, Ghabril MS, Chalasani NP, Vuppalanchi R, Orman ES, Harrison NE, Desai AP. A Comprehensive Evaluation of Emergency Department Utilization by Patients With Cirrhosis. Am J Gastroenterol 2024:00000434-990000000-01201. [PMID: 38912688 DOI: 10.14309/ajg.0000000000002905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 06/06/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Emergency department (ED)-based care is required for cirrhosis management, yet the burden of cirrhosis-related ED healthcare utilization is understudied. We aimed to describe ED utilization within a statewide health system and compare the outcomes of high ED use (HEDU) vs non-HEDU in individuals with cirrhosis. METHODS We retrospectively reviewed charts of adults with cirrhosis who presented to any of 16 EDs within the Indiana University Health system in 2021. Patient characteristics, features of the initial ED visit, subsequent 90-day healthcare use, and 360-day outcomes were collected. Multivariable logistic regression models were used to identify predictors HEDU status which was defined as ≥2 ED visits within 90 days after the index ED visit. RESULTS There were 2,124 eligible patients (mean age 61.3 years, 53% male, and 91% White). Major etiologies of cirrhosis were alcohol (38%), metabolic dysfunction-associated steatohepatitis (27%), and viral hepatitis (21%). Cirrhosis was newly diagnosed in the ED visit for 18.4%. Most common reasons for ED visits were abdominal pain (21%), shortness of breath (19%), and ascites/volume overload (16%). Of the initial ED visits, 20% (n = 424) were potentially avoidable. The overall 90-day mortality was 16%. Within 90 days, there were 366 HEDU (20%). Notable variables independently associated with HEDU were model for end-stage liver disease-sodium (adjusted odds ratio [aOR] 1.044, 95% confidence interval [CI] 1.005-1.085), prior ED encounter (aOR 1.520, 95% CI 1.136-2.034), and avoidable initial ED visit (aOR 1.938, 95% CI 1.014-3.703). DISCUSSION Abdominal pain, shortness of breath, and ascites/fluid overload are the common presenting reasons for ED visits for patients with cirrhosis. Patients with cirrhosis presenting to the ED experience a 90-day mortality rate of 16%, and among those who initially visited the ED, 20% were HEDU. We identified several variables independently associated with HEDU. Our observations pave the way for developing interventions to optimize the care of patients with cirrhosis presenting to the ED and to lower repeated ED visits.
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Affiliation(s)
- Swetha Parvataneni
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Yara Sarkis
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Michelle Haugh
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Brittany Baker
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Qing Tang
- Department of Biostatistics, Indiana University, Indianapolis, Indiana, USA
| | - Lauren D Nephew
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Naga P Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Raj Vuppalanchi
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | | | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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Chang CP, Lin CJ, Fann WC, Hsieh CH. Identifying necrotizing soft tissue infection using infectious fluid analysis and clinical parameters based on machine learning algorithms. Heliyon 2024; 10:e29578. [PMID: 38707339 PMCID: PMC11066613 DOI: 10.1016/j.heliyon.2024.e29578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 05/07/2024] Open
Abstract
Background Determining the presence of necrotizing soft tissue infection (NSTI) poses a significant hurdle. As of late, there has been a notable increase in the application of artificial intelligence (AI) machine learning techniques in identifying diseases, a shift that can be attributed to their exceptional efficiency, unbiased nature, and high precision. Methods Information was gathered from a cohort of 13 patients suffering from NSTI, alongside 12 patients with cellulitis. The construction of NSTI diagnostic machine learning models utilized four different algorithms, specifically random forest, k-nearest neighbors (KNN), support vector machine (SVM), and logistic regression. These models were constructed based on 28 distinctive attributes identified through statistical examination. Following this, the diagnostic efficiency of each algorithms was evaluated. A novel random forest model, streamlined for clinical use, was later developed by focusing on 6 attributes that had the most pronounced influence on the accuracy of our initial random forest model. Results The following data was noted regarding the sensitivity and specificity of the four NSTI diagnostic models:logistic regression displayed 78.2 % and 83.7 %, KNN presented 79.1 % and 87.1 %, SVM showed 83.5 % and 86.3 %, and random forest exhibited 89.6 % and 92.9 %, respectively. In comparison, lactate levels in fluid demonstrated 100 % sensitivity and 76.9 % specificity at an optimal cut-off point of 69.6 mg/dL. Among all four machine learning models, random forest outperformed the others and also showed better results than fluid lactate. A newly constructed random forest model, created using 6 of the 13 identified features, displayed promising results in diagnosing NSTI, having a sensitivity and specificity of 90.2 % and 92.2 %, respectively. Conclusions Developing a diagnostic model for NSTI employing the random forest algorithm has resulted in a diagnostic technique that is more efficient, cost-effective, and expedient. This approach could provide healthcare practitioners with the tools to identify and manage NSTI with greater efficacy.
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Affiliation(s)
- Chia-Peng Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County, 613, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, No.2, Sec. W., Jiapu Rd., Puzi City, Chiayi County, 613, Taiwan
| | - Chung-Jen Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County, 613, Taiwan
| | - Wen-Chih Fann
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County, 613, Taiwan
| | - Chiao-Hsuan Hsieh
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No. 6, W. Sec., Jiapu Rd., Puzih City, Chiayi County, 613, Taiwan
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Jeong JH, Lee SB, Sung A, Shin H, Kim DH. Factors predicting mortality in patients with alcoholic liver cirrhosis visiting the emergency department. Medicine (Baltimore) 2023; 102:e33074. [PMID: 36827072 PMCID: PMC11309678 DOI: 10.1097/md.0000000000033074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/25/2023] Open
Abstract
Liver cirrhosis (LC) is a major cause of morbidity and mortality worldwide and is becoming a regional and healthcare burden. South Korea is one of the 10 countries with the highest age standardized prevalence of decompensated LC. Moreover, the proportion of patients with alcoholic LC is increasing and there has been no decrease in the incidence of decompensated alcoholic LC. Patients with decompensated LC frequently visit the emergency department (ED). Several studies focused on patients with LC who visited the ED, but the studies about alcoholic LC were limited. This study aimed to identify predicting factors for mortality in alcoholic LC patients visiting the ED. This was a retrospective study of alcoholic LC patients who visited an ED between November 2017 and June 2021. The baseline characteristics, complications of LC, model for end-stage liver disease (MELD) score, and laboratory values including lactate were assessed. The primary outcome was in-hospital mortality. In total, 433 patients with alcoholic LC were included for analysis and the in hospital mortality rate was 15.9% (n = 69). Univariate regression analyses identified that MELD score, lactate, platelet, international normalized ratio, bilirubin, creatinine, albumin, and C-reactive protein (CRP) predicted in-hospital mortality. Multivariate regression analysis showed that MELD score, lactate, albumin, and CRP were significantly associated with in-hospital mortality. MELD score, lactate, albumin, and CRP predicted the mortality in alcoholic LC patients visiting the ED.
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Affiliation(s)
- Jin Hee Jeong
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
- Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Sang Bong Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Aejin Sung
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Hyuntack Shin
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Dong Hoon Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
- Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
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Morales V, González A, Cabello-Verrugio C. Upregulation of CCL5/RANTES Gene Expression in the Diaphragm of Mice with Cholestatic Liver Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1408:201-218. [PMID: 37093429 DOI: 10.1007/978-3-031-26163-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Chronic liver diseases are a group of pathologies affecting the liver with high prevalence worldwide. Among them, cholestatic chronic liver diseases (CCLD) are characterized by alterations in liver function and increased plasma bile acids. Secondary to liver disease, under cholestasis, is developed sarcopenia, a skeletal muscle dysfunction with decreased muscle mass, strength, and physical function. CCL5/RANTES is a chemokine involved in the immune and inflammatory response. Indeed, CCL5 is a myokine because it is produced by skeletal muscle. Several studies show that bile acids induce CCL5/RANTES expression in liver cells. However, it is unknown if the expression of CCL5/RANTES is changed in the skeletal muscle of mice with cholestatic liver disease. We used a murine model of cholestasis-induced sarcopenia by intake of hepatotoxin 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC diet), in which we detected the mRNA levels for ccl5. We determined that mice fed the DDC diet presented high levels of serum bile acids and developed typical features of sarcopenia. Under these conditions, we detected the ccl5 gene expression in diaphragm muscle showing elevated mRNA levels compared to mice fed with a standard diet (chow diet). Our results collectively suggest an increased ccl5 gene expression in the diaphragm muscle concomitantly with elevated serum bile acids and the development of sarcopenia.
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Affiliation(s)
- Vania Morales
- Laboratory of Muscle Pathology, Fragility and Aging, Faculty of Life Sciences, Universidad Andres Bello, Santiago, 8370146, Chile
- Millennium Institute on Immunology and Immunotherapy, Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile
- Center for the Development of Nanoscience and Nanotechnology (CEDENNA), Universidad de Santiago de Chile, Santiago, Chile
| | - Andrea González
- Laboratory of Muscle Pathology, Fragility and Aging, Faculty of Life Sciences, Universidad Andres Bello, Santiago, 8370146, Chile
- Millennium Institute on Immunology and Immunotherapy, Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile
- Center for the Development of Nanoscience and Nanotechnology (CEDENNA), Universidad de Santiago de Chile, Santiago, Chile
| | - Claudio Cabello-Verrugio
- Laboratory of Muscle Pathology, Fragility and Aging, Faculty of Life Sciences, Universidad Andres Bello, Santiago, 8370146, Chile.
- Millennium Institute on Immunology and Immunotherapy, Faculty of Life Sciences, Universidad Andres Bello, Santiago, Chile.
- Center for the Development of Nanoscience and Nanotechnology (CEDENNA), Universidad de Santiago de Chile, Santiago, Chile.
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Tan M, Adjetey A, Wee C, Perry I, Corbett C, Olajide A, Yamamoto A, Owen J, Mumtaz S. Decompensated cirrhosis: targeted training of acute medical teams to improve quality of care in first 24 hours. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:1112-1119. [PMID: 36416629 DOI: 10.12968/bjon.2022.31.21.1112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND A quality improvement project in a secondary care centre was initiated to investigate and evaluate the impact of staff education and the use of the British Society of Gastroenterology/British Association for the Study of the Liver cirrhosis care bundle in improving care of patients admitted to hospital with decompensated liver cirrhosis. METHOD A staff training programme was implemented, involving around 30 health professionals consisting of consultants, junior doctors, physician associates and nurses from the acute medical unit. A review of electronic documentation and analysis of key clinical parameters, pre- and post-intervention, was carried out. RESULTS The data show that the intervention has led to an improvement in patient management and clinical outcomes. CONCLUSION This project illustrates that collaboration between hepatology and medical teams, with emphasis on education and training, benefits patients who present to hospital with decompensated liver cirrhosis.
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Affiliation(s)
- Maria Tan
- Gastroenterology/Hepatology Advanced Clinical Practitioner, The Royal Wolverhampton NHS Trust, Wolverhampton
| | - Andrea Adjetey
- Acute Medicine Consultant, The Royal Wolverhampton NHS Trust, Wolverhampton
| | - Catalina Wee
- Acute Medical Unit Senior Sister, The Royal Wolverhampton NHS Trust, Wolverhampton
| | - Ian Perry
- Gastroenterology/Hepatology Consultant, The Royal Wolverhampton NHS Trust, Wolverhampton
| | - Chris Corbett
- Gastroenterology/Hepatology Consultant and Clinical Director, The Royal Wolverhampton NHS Trust, Wolverhampton
| | - Azeez Olajide
- Acute Medicine Consultant, The Royal Wolverhampton NHS Trust, Wolverhampton
| | - Aaron Yamamoto
- Gastroenterology/Hepatology Consultant, The Royal Wolverhampton NHS Trust, Wolverhampton
| | - James Owen
- Time of writing was QI Programme Partner, The Royal Wolverhampton NHS Trust, Wolverhampton
| | - Saqib Mumtaz
- Gastroenterology/Hepatology Consultant, The Royal Wolverhampton NHS Trust, Wolverhampton
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Mayr U, Lukas M, Elnegouly M, Vogt C, Bauer U, Ulrich J, Schmid RM, Huber W, Lahmer T. Ascitic Interleukin 6 Is Associated with Poor Outcome and Spontaneous Bacterial Peritonitis: A Validation in Critically Ill Patients with Decompensated Cirrhosis. J Clin Med 2020; 9:jcm9092865. [PMID: 32899730 PMCID: PMC7564827 DOI: 10.3390/jcm9092865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/27/2020] [Accepted: 09/02/2020] [Indexed: 02/08/2023] Open
Abstract
Decompensated cirrhosis predisposes to infectious diseases and acute-on-chronic liver failure (ACLF) in critically ill patients. Infections like spontaneous bacterial peritonitis (SBP) are frequently associated with multi-organ failure and increased mortality. Consequently, reliable predictors of outcome and early diagnostic markers of infection are needed to improve individualized therapy. This study evaluates the prognostic role of ascitic interleukin 6 in 64 patients with cirrhosis admitted to our intensive care unit (ICU). In addition, we analysed the diagnostic ability of ascitic interleukin 6 in a subgroup of 19 patients with SBP. Baseline ascitic interleukin 6 performed well in predicting 3-month mortality in patients with decompensated cirrhosis (area under curve (AUC) = 0.802), as well as in patients fulfilling ACLF-criteria (AUC = 0.807). Ascitic interleukin 6 showed a moderate prognostic advantage compared with common clinical scores and proinflammatory parameters. Moreover, ascitic interleukin 6 had a sufficient diagnostic ability to detect SBP (AUC = 0.901) and was well correlated with ascitic polymorphonuclear neutrophils in SBP (p = 0.002). Interestingly, ascitic interleukin 6 revealed a high predictive value to rule out apparent infections on admission to ICU (AUC = 0.904) and to identify patients with “culture-positive SBP” (AUC = 0.856). Ascitic interleukin 6 is an easily-applicable proinflammatory biomarker with high prognostic and diagnostic relevance in critically ill patients with liver cirrhosis.
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Affiliation(s)
- Ulrich Mayr
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
- Correspondence: ; Tel.: +49-89-4140-5226; Fax: +49-89-4140-4742
| | - Marina Lukas
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Mayada Elnegouly
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Christine Vogt
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany;
| | - Ulrike Bauer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Joerg Ulrich
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Roland M. Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Wolfgang Huber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
| | - Tobias Lahmer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, D-81675 München, Germany; (M.L.); (M.E.); (U.B.); (J.U.); (R.M.S.); (W.H.); (T.L.)
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NUTRIC and Modified NUTRIC are Accurate Predictors of Outcome in End-Stage Liver Disease: A Validation in Critically Ill Patients with Liver Cirrhosis. Nutrients 2020; 12:nu12072134. [PMID: 32709104 PMCID: PMC7400844 DOI: 10.3390/nu12072134] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 12/15/2022] Open
Abstract
Malnutrition in critically ill patients with cirrhosis is a frequent but often overlooked complication with high prognostic relevance. The Nutrition Risk in Critically ill (NUTRIC) score and its modified variant (mNUTRIC) were established to assess the nutrition risk of intensive care unit patients. Considering the high mortality of cirrhosis in critically ill patients, this study aims to evaluate the discriminative ability of NUTRIC and mNUTRIC to predict outcome. We performed a retro-prospective evaluation in 150 Caucasian cirrhotic patients admitted to our ICU. Comparative prognostic analyses between NUTRIC and mNUTRIC were assessed in 114 patients. On ICU admission, a large proportion of 65% were classified as high NUTRIC (6-10) and 75% were categorized as high mNUTRIC (5-9). High nutritional risk was linked to disease severity and poor outcome. NUTRIC was moderately superior to mNUTRIC in prediction of 28-day mortality (area under curve 0.806 vs. 0.788) as well as 3-month mortality (area under curve 0.839 vs. 0.819). We found a significant association of NUTRIC and mNUTRIC with MELD, CHILD, renal function, interleukin 6 and albumin, but not with body mass index. NUTRIC and mNUTRIC are characterized by high prognostic accuracy in critically ill patients with cirrhosis. NUTRIC revealed a moderate advantage in prognostic ability compared to mNUTRIC.
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Predictors of Emergency Room Admission in Patients With Liver Cirrhosis: A Prospective, Descriptive Study. Gastroenterol Nurs 2020; 43:65-75. [PMID: 31990874 DOI: 10.1097/sga.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study aimed to identify the predictors of emergency room (ER) admission in patients with liver cirrhosis. The data of 215 patients with liver cirrhosis who visited the ER were collected from January 1 to March 15, 2017, at Yeungnam hospital in Daegu city, South Korea. Measurement scales were designed on the basis of the liver function test and evaluation of anxiety and depression, self-care, and family support. Diseases that cause liver cirrhosis, their associated characteristics, and respective hematologic examination results were reviewed from the hospital's electronic medical records. Among the 215 patients with liver cirrhosis who visited the ER, 47 (21.9%) had previous ER admissions, whereas 168 (78.1%) had none. Fifteen predictive factors that were significantly different between the ER admission and non-ER admission groups were included as variables in logistic regression analysis. This analysis revealed that the 3 significant predictors of ER admission in patients with liver cirrhosis were number of prior complications, serum bilirubin level, and self-care compliance. An increased number of prior complications, increased bilirubin level, and low self-care compliance increased the ER admission rates in patients with liver cirrhosis. Thus, further studies are necessary to measure the effects of nursing intervention strategies based on these findings.
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Prognosis of cirrhotic patients admitted to Emergency Departments: A multicenter study. Am J Emerg Med 2019; 37:1317-1321. [DOI: 10.1016/j.ajem.2018.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/01/2018] [Accepted: 10/10/2018] [Indexed: 11/19/2022] Open
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Gessolo Lins PR, Carvalho Padilha WS, Magalhaes Giradin Pimentel CF, Costa Batista M, Teixeira de Gois AF. Risk factors, mortality and acute kidney injury outcomes in cirrhotic patients in the emergency department. BMC Nephrol 2018; 19:277. [PMID: 30342475 PMCID: PMC6196026 DOI: 10.1186/s12882-018-1061-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 09/27/2018] [Indexed: 12/19/2022] Open
Abstract
Background Acute kidney injury (AKI) is common in cirrhotic patients and is associated with negative outcomes. The aim of this study was to evaluate the presence of AKI and its progression according to KDIGO (Kidney Disease: Improving Global Outcomes) criteria in cirrhotic patients admitted to the emergency department and to determine the association of AKI with hospital mortality. Methods This retrospective study included 258 cirrhotic patients admitted to the emergency department of a university hospital from March 2015 to February 2017. AKI was diagnosed and classified according to the KDIGO criteria. Results The overall incidence of AKI in cirrhotic patients was 53.9%, and the overall hospital mortality was 28.4%. Mortality was associated with the presence, stage, and progression of AKI. Patients with AKI stage 1 and sCr < 1.5 mg/dl (KDIGO 1a) had a lower mortality rate than patients with AKI stage 1 and sCr > 1.5 mg/dl (KDIGO 1b). In the logistic regression analysis, three variables were independently associated with hospital mortality: cancer, AKI and progression of AKI. Conclusions According to the data presented, a single measure of creatinine is not enough, and there is a need for meticulous follow-up of the renal function of patients with hepatic cirrhosis hospitalized in an emergency unit. In addition, this study reinforces the need for subclassification of KDIGO 1 in cirrhotic patients, since patients with acute renal injury and creatinine greater than 1.5 mg/dL present a worse clinical outcome.
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Affiliation(s)
- Paulo Ricardo Gessolo Lins
- Discipline of Nephrology, Federal University of São Paulo, Rua Botucatu, 591 - 15 ° andar - Cj153 - Vila Clementino, São Paulo, SP, 04023-062, Brazil.
| | - Wallace Stwart Carvalho Padilha
- Discipline of Nephrology, Federal University of São Paulo, Rua Botucatu, 591 - 15 ° andar - Cj153 - Vila Clementino, São Paulo, SP, 04023-062, Brazil
| | - Carolina Frade Magalhaes Giradin Pimentel
- Discipline of Medicine of Urgency and Evidence-Based Medicine from the Department of Medicine, Federal University of São Paulo, Rua Napoleão de Barros, 865 - Vila Clementino, São Paulo, SP, 04023-090, Brazil
| | - Marcelo Costa Batista
- Discipline of Nephrology, Federal University of São Paulo, Rua Botucatu, 591 - 15 ° andar - Cj153 - Vila Clementino, São Paulo, SP, 04023-062, Brazil
| | - Aécio Flávio Teixeira de Gois
- Discipline of Medicine of Urgency and Evidence-Based Medicine from the Department of Medicine, Federal University of São Paulo, Rua Napoleão de Barros, 865 - Vila Clementino, São Paulo, SP, 04023-090, Brazil
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11
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Alexopoulou A, Agiasotelli D, Vasilieva LE, Dourakis SP. Bacterial translocation markers in liver cirrhosis. Ann Gastroenterol 2017; 30:486-497. [PMID: 28845103 PMCID: PMC5566768 DOI: 10.20524/aog.2017.0178] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 06/19/2017] [Indexed: 12/12/2022] Open
Abstract
Bacterial translocation (BT) is an important mechanism in the development of infection in liver cirrhosis. The migration and colonization of bacteria and/or bacterial products from the bowel to mesenteric lymph nodes is a controlled process in healthy persons. Increased intestinal permeability, bacterial overgrowth and defect of gut-associated lymphatic tissue promote impaired BT in cirrhotics. We reviewed the reports on markers used for the evaluation of BT published between 1987 and 2016. We focused on the clinical consequences of BT in cirrhosis, as indicated by the values of the BT markers. Patients with cirrhosis are reported to have elevated levels of surrogate markers associated with BT compared with controls. The most widely used BT parameters are C-reactive protein, procalcitonin, bacterial DNA, endotoxin or lipopolysaccharide, lipopolysaccharide binding protein, calprotectin, and bactericidal/permeability increasing protein. High levels of these factors in serum and/or ascitic fluid in humans may be associated with advanced liver disease, hemodynamic instability, high levels of proinflammatory cytokines, susceptibility to the development of severe or recurrent infections, acute-on-chronic liver failure, hepatic encephalopathy, hepatorenal syndrome and poor prognosis during follow up. In conclusion, high levels of BT markers are associated with a high inflammatory response, increased complications of liver cirrhosis and occasionally high fatality rates.
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Affiliation(s)
- Alexandra Alexopoulou
- 2 Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, "Hippokration" Hospital, Athens, Greece
| | - Danai Agiasotelli
- 2 Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, "Hippokration" Hospital, Athens, Greece
| | - Larisa E Vasilieva
- 2 Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, "Hippokration" Hospital, Athens, Greece
| | - Spyros P Dourakis
- 2 Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, "Hippokration" Hospital, Athens, Greece
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Hospital mortality in cirrhotic patients at a tertiary care center. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2016.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Hospital mortality in cirrhotic patients at a tertiary care center. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2017; 82:203-209. [PMID: 28433485 DOI: 10.1016/j.rgmx.2016.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 07/28/2016] [Accepted: 10/10/2016] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Cirrhosis of the liver is known for its high risk of mortality associated with episodes of acute decompensation. There is an even greater risk in patients that present with acute-on-chronic liver failure. The identification of patients at higher risk for adverse outcomes can aid in making the clinical decisions that will improve the prognosis for these patients. AIMS To determine in-hospital mortality and evaluate the epidemiologic and clinical characteristics of patients with cirrhosis of the liver seen at a tertiary referral hospital. METHODOLOGY A descriptive, observational, cohort study was conducted on adult patients with cirrhosis of the liver, admitted to a tertiary care center in Bucaramanga, Colombia, within the time frame of March 1, 2015 and February 29, 2016. RESULTS Eighty-one patients with a mean age of 62 years were included in the study. The main etiology of the cirrhosis was alcoholic (59.3%). In-hospital mortality was 23.5% and the most frequent cause of death was septic shock (68.4%), followed by hypovolemic shock (10.5%). A MELD score≥18, a leukocyte count>12,000/ul, and albumin levels below<2.5g/dl were independent factors related to hospital mortality. CONCLUSIONS In-hospital mortality in cirrhotic patients is high. Sepsis and bleeding are the 2 events leading to acute-on-chronic liver failure and death. A high MELD score, elevated leukocyte count, and low level of albumin are related to poor outcome during hospitalization. Adjusted prevention-centered public health measures and early and opportune diagnosis of this disease are needed to prevent the development of complications and to improve outcome in cirrhotic patients.
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Papp M, Tornai T, Vitalis Z, Tornai I, Tornai D, Dinya T, Sumegi A, Antal-Szalmas P. Presepsin teardown - pitfalls of biomarkers in the diagnosis and prognosis of bacterial infection in cirrhosis. World J Gastroenterol 2016; 22:9172-9185. [PMID: 27895404 PMCID: PMC5107598 DOI: 10.3748/wjg.v22.i41.9172] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the diagnostic and prognostic value of presepsin in cirrhosis-associated bacterial infections.
METHODS Two hundred and sixteen patients with cirrhosis were enrolled. At admission, the presence of bacterial infections and level of plasma presepsin, serum C-reactive protein (CRP) and procalcitonin (PCT) were evaluated. Patients were followed for three months to assess the possible association between presepsin level and short-term mortality.
RESULTS Present 34.7 of patients had bacterial infection. Presepsin levels were significantly higher in patients with infection than without (median, 1002 pg/mL vs 477 pg/mL, P < 0.001), increasing with the severity of infection [organ failure (OF): Yes vs No, 2358 pg/mL vs 710 pg/mL, P < 0.001]. Diagnostic accuracy of presepsin for severe infections was similar to PCT and superior to CRP (AUC-ROC: 0.85, 0.85 and 0.66, respectively, P = NS for presepsin vs PCT and P < 0.01 for presepsin vs CRP). At the optimal cut-off value of presepsin > 1206 pg/mL sensitivity, specificity, positive predictive values and negative predictive values were as follows: 87.5%, 74.5%, 61.8% and 92.7%. The accuracy of presepsin, however, decreased in advanced stage of the disease or in the presence of renal failure, most probably because of the significantly elevated presepsin levels in non-infected patients. 28-d mortality rate was higher among patients with > 1277 pg/mL compared to those with ≤ 1277 pg/mL (46.9% vs 11.6%, P < 0.001). In a binary logistic regression analysis, however, only PCT (OR = 1.81, 95%CI: 1.09-3.01, P = 0.022) but neither presepsin nor CRP were independent risk factor for 28-d mortality after adjusting with MELD score and leukocyte count.
CONCLUSION Presepsin is a valuable new biomarker for defining severe infections in cirrhosis, proving same efficacy as PCT. However, it is not a useful marker of short-term mortality.
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