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Song DS, Kim HY, Jung YK, Kim TH, Yim HJ, Yoon EL, Suk KT, Yoo JJ, Kim SG, Kim MY, Chang Y, Jeong SW, Jang JY, Kim SE, Kim JH, Park JG, Kim W, Yang JM, Kim DJ, Choudhury AK, Arora V, Sarin SK. Dynamic analysis of acute deterioration in chronic liver disease patients using modified quick sequential organ failure assessment. Clin Mol Hepatol 2024; 30:388-405. [PMID: 38600873 PMCID: PMC11261223 DOI: 10.3350/cmh.2023.0563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/23/2024] [Accepted: 04/09/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND/AIMS Quick sequential organ failure assessment (qSOFA) is believed to identify patients at risk of poor outcomes in those with suspected infection. We aimed to evaluate the ability of modified qSOFA (m-qSOFA) to identify high-risk patients among those with acutely deteriorated chronic liver disease (CLD), especially those with acute-onchronic liver failure (ACLF). METHODS We used data from both the Korean Acute-on-Chronic Liver Failure (KACLiF) and the Asian Pacific Association for the Study of the Liver ACLF Research Consortium (AARC) cohorts. qSOFA was modified by replacing the Glasgow Coma Scale with hepatic encephalopathy, and an m-qSOFA ≥2 was considered high. RESULTS Patients with high m-qSOFA had a significantly lower 1-month transplant-free survival (TFS) in both cohorts and higher organ failure development in KACLiF than those with low m-qSOFA (Ps<0.05). Subgroup analysis by ACLF showed that patients with high m-qSOFA had lower TFS than those with low m-qSOFA. m-qSOFA was an independent prognostic factor (hazard ratios, HR=2.604, 95% confidence interval, CI 1.353-5.013, P=0.004 in KACLiF and HR=1.904, 95% CI 1.484- 2.442, P<0.001 in AARC). The patients with low m-qSOFA at baseline but high m-qSOFA on day 7 had a significantly lower 1-month TFS than those with high m-qSOFA at baseline but low m-qSOFA on day 7 (52.6% vs. 89.4%, P<0.001 in KACLiF and 26.9% vs. 61.5%, P<0.001 in AARC). CONCLUSION Baseline and dynamic changes in m-qSOFA may identify patients with a high risk of developing organ failure and short-term mortality among CLD patients with acute deterioration.
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Affiliation(s)
- Do Seon Song
- Department of Internal Medicine, St. Vincent’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Hee Yeon Kim
- Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Tae Hyung Kim
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Eileen L Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong-ju Yoo
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Chang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sung-Eun Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jung-Hee Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Jung Gil Park
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Won Kim
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jin Mo Yang
- Department of Internal Medicine, St. Vincent’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Korean Acute-on-Chronic Liver Failure (KACLiF) study group
- Department of Internal Medicine, St. Vincent’s Hospital, The Catholic University of Korea, Seoul, Korea
- Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - APASL ACLF Research Consortium (AARC) for APASL ACLF working party
- Department of Internal Medicine, St. Vincent’s Hospital, The Catholic University of Korea, Seoul, Korea
- Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Sikerwar S, Zand S, Steel P, Jesudian A. Management of patients with cirrhosis in the emergency department: Implications for hospitalization outcomes. Liver Transpl 2024; 30:94-102. [PMID: 37851401 DOI: 10.1097/lvt.0000000000000285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/11/2023] [Indexed: 10/19/2023]
Affiliation(s)
- Sandeep Sikerwar
- New York Presbyterian Weill Cornell Medical Center New York, New York, USA
- Columbia University Irving Medical Center, New York, New York, USA
| | - Sohrab Zand
- New York Presbyterian Weill Cornell Medical Center New York, New York, USA
| | - Peter Steel
- New York Presbyterian Weill Cornell Medical Center New York, New York, USA
| | - Arun Jesudian
- New York Presbyterian Weill Cornell Medical Center New York, New York, USA
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Kulkarni A, Rakam K, Avadhanam M, V P Y, Rachakonda C, Satyavadi A, Zuberi AA, Reddy S, Iyengar S, Gupta A, Sharma M, Padaki NR, Rajender R, Duvvur NR. Predictors and Outcomes of Infections in ICU Patients With Cirrhosis: A Single-Center Observational Study. Cureus 2023; 15:e47151. [PMID: 38022175 PMCID: PMC10652166 DOI: 10.7759/cureus.47151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Patients with cirrhosis are susceptible to infections, especially by multidrug-resistant organisms (MDROs). There are limited data on the incidence of culture-positive infections and the validity of Sepsis 3-criteria in patients with cirrhosis admitted to the intensive care unit (ICU) in India, which we aimed to assess. METHODS In this prospective study, we included consecutive patients with cirrhosis admitted to the ICU between November 1, 2021, and April 30, 2022. The primary objective was to compare the outcomes of patients with microbiologically proven infections with those without proven infections. The secondary objective was to assess the predictors of infections and mortality and the impact of drug-resistant organisms. RESULTS A total of 298 patients (9.4% women) were included. The incidence of microbiologically proven infection was 34% (101/298; 95%CI=27.6-41.2). Most patients (61%) had healthcare-associated infections, Gram-negative organisms accounted for 75.3%, and bacteremia was the commonest site. Drug-resistant organisms accounted for 52.5% (53/101; 95%CI=39.3-68.7), of which 39.6% were multidrug-resistant (MDR) and 12.8% were extensively drug-resistant (XDR). Mortality was significantly higher in patients with proven infections than those without (61.4% vs. 44.2%; P=0.007). The sequential organ failure assessment (SOFA) score (OR=1.91; 95%CI=1.04-3.52; P<0.001) and presence of fever and/or positive quick SOFA (qSOFA; OR=1.91;1.04-3.52; P=0.03) were associated with an increased risk of infections. The SOFA score (OR=1.06;95%CI=1.002-1.12; P=0.04), MELD NA score (OR=1.08;95%CI=1.05-1.12; P<0.001), and presence of fever and/or positive qSOFA (OR=2.19; 95%CI=1.27-3.76; P=0.005) predicted mortality. CONCLUSIONS One-third of the patients with cirrhosis admitted to the ICU had microbiologically proven infection, and the mortality rate in such patients was high. SOFA, qSOFA, and fever can predict microbiologically proven infections and mortality in patients with cirrhosis.
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Affiliation(s)
- Anand Kulkarni
- Hepatology, Asian Institute of Gastroenterology (AIG), Hyderabad, IND
| | - Kalyan Rakam
- Critical Care Medicine, Asian Institute of Gastroenterology (AIG), Hyderabad, IND
| | - Mahathi Avadhanam
- Hepatology, Asian Institute of Gastroenterology (AIG), Hyderabad, IND
| | - Yogita V P
- Clinical Pharmacy, Asian Institute of Gastroenterology (AIG), Hyderabad, IND
| | | | - Anveshi Satyavadi
- Critical Care Medicine, Asian Institute of Gastroenterology (AIG), Hyderabad, IND
| | - Asim A Zuberi
- Clinical Pharmacy, Asian Institute of Gastroenterology (AIG), Hyderabad, IND
| | - Santhosh Reddy
- Clinical Pharmacy, Asian Institute of Gastroenterology (AIG), Hyderabad, IND
| | - Sowmya Iyengar
- Hepatology, Asian Institute of Gastroenterology (AIG), Hyderabad, IND
| | - Anand Gupta
- Critical Care Medicine, Asian Institute of Gastroenterology (AIG), Hyderabad, IND
| | - Mithun Sharma
- Hepatology, Asian Institute of Gastroenterology (AIG), Hyderabad, IND
| | - Nagaraja R Padaki
- Hepatology, Asian Institute of Gastroenterology (AIG), Hyderabad, IND
| | - Reddy Rajender
- Perelman School of Medicine, University of Pennsylvania, Philadephia, USA
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4
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Jagdish RK, Roy A, Kumar K, Premkumar M, Sharma M, Rao PN, Reddy DN, Kulkarni AV. Pathophysiology and management of liver cirrhosis: from portal hypertension to acute-on-chronic liver failure. Front Med (Lausanne) 2023; 10:1060073. [PMID: 37396918 PMCID: PMC10311004 DOI: 10.3389/fmed.2023.1060073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 05/19/2023] [Indexed: 07/04/2023] Open
Abstract
Cirrhosis transcends various progressive stages from compensation to decompensation driven by the severity of portal hypertension. The downstream effect of increasing portal hypertension severity leads to various pathophysiological pathways, which result in the cardinal complications of cirrhosis, including ascites, variceal hemorrhage, and hepatic encephalopathy. Additionally, the severity of portal hypertension is the central driver for further advanced complications of hyperdynamic circulation, hepatorenal syndrome, and cirrhotic cardiomyopathy. The management of these individual complications has specific nuances which have undergone significant developments. In contrast to the classical natural history of cirrhosis and its complications which follows an insidious trajectory, acute-on-chronic failure (ACLF) leads to a rapidly downhill course with high short-term mortality unless intervened at the early stages. The management of ACLF involves specific interventions, which have quickly evolved in recent years. In this review, we focus on complications of portal hypertension and delve into an approach toward ACLF.
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Affiliation(s)
- Rakesh Kumar Jagdish
- Department of Hepatology, Gastroenterology and Liver Transplant Medicine, Metro Hospital, Noida, India
| | - Akash Roy
- Department of Gastroenterology, Institute of Gastrosciences and Liver Transplantation, Apollo Hospitals, Kolkata, India
| | - Karan Kumar
- Department of Hepatology, Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mithun Sharma
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
| | - Padaki Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
| | - Duvvur Nageshwar Reddy
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
| | - Anand V. Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
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5
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Vazquez C, Gutierrez-Acevedo MN, Barbero S, Notari LDC, Agozino M, Fernandez JL, Anders MM, Grigera NL, Antinucci F, Orozco-Ganem ONF, Murga MD, Perez MD, Palazzo AG, Rejtman LM, Duarte IG, Vorobioff JD, Trevizan V, Bulaty S, Bessone F, Valverde M, Elizondo M, Borzi SM, Stieben TE, Masola AC, Ferretti SE, Arufe D, Demirdjian E, Raffa MP, Peralta M, Fainboim HA, Vazquez CE, Ruiz PM, Martínez JE, Heffner LA, Odzak A, Dirchwolf M, Smud A, Mendizabal M, Calzetta PA, Martinez A, Tomatis J, Bruno A, Ramos A, Pages J, Tevez S, Gadano AC, Giunta DH, Marciano S. Clinical and microbiological characteristics of bacterial infections in patients with cirrhosis. A prospective cohort study from Argentina and Uruguay. Ann Hepatol 2023; 28:101097. [PMID: 37030570 DOI: 10.1016/j.aohep.2023.101097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/01/2023] [Accepted: 03/03/2023] [Indexed: 04/10/2023]
Abstract
INTRODUCTION AND OBJECTIVES there is insufficient data regarding bacterial infections in patients with cirrhosis to support recommendations for empiric antibiotic treatments, particularly in Latin America. This study aimed to evaluate bacterial infection's clinical impact and microbiological characteristics, intending to serve as a platform to revise current practices. MATERIALS AND METHODS a multicenter prospective cohort study of patients with cirrhosis and bacterial infections from Argentina and Uruguay. Patients and infection-related information were collected, focusing on microbiology, antibiotic susceptibility patterns, and outcomes. RESULTS 472 patients were included. Spontaneous bacterial infections and urinary tract infections (UTI) were registered in 187 (39.6%) and 116 (24.6%) patients, respectively, representing the most common infections. Of the 256 culture-positive infections, 103 (40.2%) were caused by multidrug-resistant organisms (reaching 50% for UTI), and 181 (70.7%) received adequate initial antibiotic treatment. The coverage of cefepime and ceftriaxone was over 70% for the empirical treatment of community-acquired spontaneous infections, but ceftazidime´s coverage was only 40%. For all cases of UTI and for healthcare-associated or nosocomial spontaneous bacterial infections, the lower-spectrum antibiotics that covered at least 70% of the isolations were imipenem and meropenem. During hospitalization, a second bacterial infection was diagnosed in 9.8% of patients, 23.9% required at least one organ support, and 19.4% died. CONCLUSIONS short-term mortality of bacterial infections in patients with cirrhosis is very high, and a high percentage were caused by multidrug-resistant organisms, particularly in UTIs. The information provided might serve to adapt recommendations, particularly related to empirical antibiotic treatment in Argentina and Uruguay. The study was registered in Clinical Trials (NCT03919032).
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Affiliation(s)
- Carolina Vazquez
- Hospital Italiano de Buenos Aires, Internal Medicine Department, Buenos Aires, Argentina.
| | | | - Sabrina Barbero
- Hospital Churruca Visca, Liver Unit, Buenos Aires, Argentina
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sofía Bulaty
- Hospital provincial del Centenario, Liver Unit, Rosario, Argentina
| | - Fernando Bessone
- Hospital provincial del Centenario, Liver Unit, Rosario, Argentina
| | - Marcelo Valverde
- Unidad Bi-Institucional de Trasplante Hepático, Hospital de Clínicas - Hospital Militar, Liver Unit, Montevideo, Uruguay
| | - Martín Elizondo
- Unidad Bi-Institucional de Trasplante Hepático, Hospital de Clínicas - Hospital Militar, Liver Unit, Montevideo, Uruguay
| | | | | | | | | | - Diego Arufe
- Sanatorio Sagrado Corazón, Liver Unit, Buenos Aires, Argentina
| | | | - María Pia Raffa
- Sanatorio Sagrado Corazón, Liver Unit, Buenos Aires, Argentina
| | | | | | | | | | | | | | - Andrea Odzak
- Hospital Argerich, Liver Unit, Buenos Aires, Argentina
| | | | - Astrid Smud
- Hospital Italiano de Buenos Aires, Infectious Diseases Section, Buenos Aires, Argentina
| | | | | | - Ana Martinez
- Hospital Fernández, Liver Unit, Buenos Aires, Argentina
| | - Jesica Tomatis
- Hospital Privado de Rosario, Liver Unit, Rosario, Argentina
| | - Andres Bruno
- Hospital Argerich, Liver Unit, Buenos Aires, Argentina
| | - Agñel Ramos
- Sanatorio Parque, Liver Unit, Rosario, Argentina
| | - Josefina Pages
- Hospital Universitario Austral, Liver Unit, Pilar, Argentina
| | - Silvina Tevez
- Sanatorio Güemes, Liver Unit, Buenos Aires, Argentina
| | - Adrian Carlos Gadano
- Hospital Italiano de Buenos Aires, Liver Unit, Buenos Aires, Argentina; Hospital Italiano de Buenos Aires, Department of Research, Buenos Aires, Argentina
| | - Diego H Giunta
- Hospital Italiano de Buenos Aires, Department of Research, Buenos Aires, Argentina; Center for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Sebastián Marciano
- Hospital Italiano de Buenos Aires, Liver Unit, Buenos Aires, Argentina; Hospital Italiano de Buenos Aires, Department of Research, Buenos Aires, Argentina
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Abstract
Patients with cirrhosis frequently require admission to the intensive care unit (ICU). Common indications for admission to ICU include one or more reasons of sepsis, shock due to any cause, acute gastrointestinal bleeding, and altered mentation either due to hepatic encephalopathy, alcohol withdrawal/intoxication, or metabolic encephalopathy. The appropriate critical care of an individual can determine the outcomes of these sick patients. The Airway, Breathing, Circulation, Disability (ABCD) approach to a patient admitted to ICU includes airway, breathing, circulation, and disability management. In this review, the authors discuss the common indications for ICU admission in a patient with cirrhosis and also their management.
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Affiliation(s)
- Mahathi Avadhanam
- Department of Emergency Medicine, Queen Elizabeth hospital, London, UK
| | - Anand V Kulkarni
- Department of Hepatology, AIG Hospitals, Gachibowli, Hyderabad, India-500032.
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7
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Kulkarni AV, Premkumar M, Arab JP, Kumar K, Sharma M, Reddy ND, Padaki NR, Reddy RK. Early Diagnosis and Prevention of Infections in Cirrhosis. Semin Liver Dis 2022; 42:293-312. [PMID: 35672014 DOI: 10.1055/a-1869-7607] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Strategies to prevent infection and improve outcomes in patients with cirrhosis. HAV, hepatitis A virus; HBV, hepatitis B virus; COVID-19, novel coronavirus disease 2019; NSBB, nonselective β-blocker; PPI, proton pump inhibitors.Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infections. Sepsis is an immunological response to an infectious process that leads to end-organ dysfunction and death. Preventing infections may avoid the downstream complications, and early diagnosis of infections may improve the outcomes. In this review, we discuss the pathogenesis, diagnosis, and biomarkers of infection; the incremental preventive strategies for infections and sepsi; and the consequent organ failures in cirrhosis. Strategies for primary prevention include reducing gut translocation by selective intestinal decontamination, avoiding unnecessary proton pump inhibitors' use, appropriate use of β-blockers, and vaccinations for viral diseases including novel coronavirus disease 2019. Secondary prevention includes early diagnosis and a timely and judicious use of antibiotics to prevent organ dysfunction. Organ failure support constitutes tertiary intervention in cirrhosis. In conclusion, infections in cirrhosis are potentially preventable with appropriate care strategies to then enable improved outcomes.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Juan P Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Karan Kumar
- Department of Hepatology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Mithun Sharma
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nageshwar D Reddy
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nagaraja R Padaki
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rajender K Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
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8
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Kim JH, Jun BG, Lee M, Lee HA, Kim TS, Heo JW, Moon DH, Kang SH, Suk KT, Kim MY, Kim YD, Cheon GJ, Baik SK, Kim DJ, Choi DH. Reappraisal of Sepsis-3 and CLIF-SOFA or Mortality in Patients With Cirrhosis and Infection Presenting to the Emergency Department: A Multicenter Study. Clin Mol Hepatol 2022; 28:540-552. [PMID: 35526859 PMCID: PMC9293608 DOI: 10.3350/cmh.2021.0169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 05/03/2022] [Indexed: 11/16/2022] Open
Abstract
Background/Aims Sepsis-3 criteria and quick Sequential Organ Failure Assessment (qSOFA) have been advocated to be used in defining sepsis in the general population. We aimed to compare the Sepsis-3 criteria and Chronic Liver Failure-SOFA (CLIF-SOFA) scores as predictors of in-hospital mortality in cirrhotic patients admitted to the emergency department (ED) for infections. Methods A total of 1,622 cirrhosis patients admitted at the ED for infections were assessed retrospectively. We analyzed their demographic, laboratory, and microbiological data upon diagnosis of the infection. The primary endpoint was inhospital mortality rate. The predictive performances of baseline CLIF-SOFA, Sepsis-3, and qSOFA scores for in-hospital mortality were evaluated. Results The CLIF-SOFA score proved to be significantly better in predicting in-hospital mortality (area under the receiver operating characteristic curve [AUROC], 0.80; 95% confidence interval [CI], 0.78–0.82) than the Sepsis-3 (AUROC, 0.75; 95% CI, 0.72–0.77, P<0.001) and qSOFA (AUROC, 0.67; 95% CI, 0.64–0.70; P<0.001) score. The CLIF-SOFA, CLIF-C-AD scores, Sepsis-3 criteria, septic shock, and qSOFA positivity were significantly associated with in-hospital mortality (adjusted hazard ratio [aHR], 1.24; 95% CI, 1.19–1.28; aHR, 1.13; 95% CI, 1.09–1.17; aHR, 1.19; 95% CI, 1.15–1.24; aHR, 1.88; 95% CI, 1.42–2.48; aHR, 2.06; 95% CI, 1.55–2.72; respectively; all P<0.001). For CLIF-SOFA scores ≥6, in-hospital mortality was >10%; this is the cutoff point for the definition of sepsis. Conclusions Among cirrhosis patients presenting with infections at the ED, CLIF-SOFA scores showed a better predictive performance for mortality than both Sepsis-3 criteria and qSOFA scores, and can be a useful tool of risk stratification in cirrhotic patients requiring timely intervention for infection.
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Chang YC, Fang YT, Chen HC, Lin CY, Chang YP, Tsai YH, Chen YM, Huang KT, Chang HC, Wang CC, Lin MC, Fang WF. The Survival of Septic Patients with Compensated Liver Cirrhosis Is Not Inferior to That of Septic Patients without Liver Cirrhosis: A Propensity Score Matching Analysis. J Clin Med 2022; 11:jcm11061629. [PMID: 35329955 PMCID: PMC8951259 DOI: 10.3390/jcm11061629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 02/01/2023] Open
Abstract
Background: We aimed to determine whether septic patients with liver cirrhosis (LC) had worse survival than septic patients without liver cirrhosis (WLC). We also investigated the survival of septic patients with compensated liver cirrhosis (CLC) and decompensated liver cirrhosis (DLC). Methods: This study enrolled 776 consecutive adult patients with sepsis admitted to the medical intensive care units of a tertiary referral hospital. Clinical factors and laboratory data were collected for analysis. Propensity scoring was also used for the control of selection bias. The variables included in the propensity model were age, sex, presence of diabetes mellitus, hypertension, cardiovascular accident, chronic kidney disease, malignancy, APCHE II (Acute Physiology and Chronic Health Evaluation) score, hemoglobin, and platelet data on the day when sepsis was confirmed. Seven-day, ICU, and hospital mortality were analyzed after correcting for these confounding factors. Results: Of the 776 septic patients, 64 (8.2%) septic patients presented with LC. Patients were divided into two groups—LC (n = 64) and WLC (n = 712)—which presented different rates of hospital mortality (LC: 62.5% vs. WLC: 41.0%, p = 0.001). We further separated septic patients with LC into two groups: patients with CLC (n = 24) and those with DLC (n = 40). After propensity score matching, the survival of septic patients with CLC (63.6%) was not inferior to patients WLC (54.5%) (p = 0.411). Patients with DLC had more hospital mortality, even after matching (p < 0.05). The Quick SOFA (qSOFA) score, SOFA score, and sub-SOFA score were also comparable between groups. SOFA scores were not significantly different between the CLC and WLC groups after matching. Poor SOFA scores were observed in the DLC group on days 3 and 7 after matching (p < 0.05). Conclusions: Septic patients with LC had higher mortality compared to patients WLC before matching. However, after propensity score matching, the survival of septic patients with CLC was non-inferior to patients WLC.
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Affiliation(s)
- Ya-Chun Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
- Department of Internal Medicine, Kaohsiung Municipal Min-Sheng Hospital, Kaohsiung 802, Taiwan
| | - Ying-Tang Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
| | - Hung-Cheng Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
| | - Chiung-Yu Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
| | - Yu-Ping Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
| | - Yi-Hsuan Tsai
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
| | - Yu-Mu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
| | - Kuo-Tung Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
| | - Huang-Chih Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
| | - Chin-Chou Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi 613, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (Y.-C.C.); (Y.-T.F.); (H.-C.C.); (C.-Y.L.); (Y.-P.C.); (Y.-H.T.); (Y.-M.C.); (K.-T.H.); (H.-C.C.); (C.-C.W.); (M.-C.L.)
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi 613, Taiwan
- Correspondence: ; Tel.: +886-7-7317123 (ext. 8199)
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Clar J, Oltra MR, Benavent R, Pinto C, Ruiz A, Sanchez MT, Noceda J, Redon J, Forner MJ. Prognostic value of diagnostic scales in community-acquired sepsis mortality at an emergency service. Prognosis in community-adquired sepsis. BMC Emerg Med 2021; 21:161. [PMID: 34922448 PMCID: PMC8684687 DOI: 10.1186/s12873-021-00532-1] [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: 12/07/2020] [Accepted: 09/30/2021] [Indexed: 12/16/2022] Open
Abstract
Objectives To asses the prognostic value of diagnostic scales in mortality of community-adquired sepsis and added value of additional parameters. Methods Prospective observational study of patients with community-adquired sepsis in the Emergency Room of University Hospital. The study population were patients presented in the Emergency Room with confirmed infection and practicians sepsis diagnosis. Demographics, triage vital signs, inhaled oxygen fraction, inflammatory markers, biochemistry, all-cause mortality during hospitalization and three months after were recorded. Prognostic value of qSOFA, NEWS, SOFA, SIRS, and amplified scales were calculated by using logistic regression and ROC curves. Results 201 patients, 54% male, average age 77±11,2 years were included. Sixty-three (31.5%) died during hospitalization and 24 (12%) three months after discharge. At the time of admission vital signs related with in-hospital mortality were Glasgow Coma Scale <13, respiratory rate ≥22 bpm, temperature, oxygen desaturation, high flow oxygen therapy and heart rate. Patients dead in-hospital had lower PaCO2, higher lactate, glucose and creatinine. Greater predictive capacity of the scales, from higher to lower, was: qSOFA, NEWS2, SOFA and SIRS. Amplified scales with lactate >2mg/dl, glucose, blood level >190mg/dl and PaCO2 <35mmHg improved predictive value. Conclusion Amplified-qSOFA and amplified-NEWS2 scales at Emergency Department may offer a better prognostic of septic patients mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00532-1.
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Affiliation(s)
- Jorge Clar
- Clinic Hospital. University of Valencia, 46010, València, Spain
| | | | - Raquel Benavent
- Clinic Hospital. University of Valencia, 46010, València, Spain
| | - Carolina Pinto
- Clinic Hospital. University of Valencia, 46010, València, Spain
| | - Adrian Ruiz
- Clinic Hospital. University of Valencia, 46010, València, Spain
| | | | - Jose Noceda
- Clinic Hospital. University of Valencia, 46010, València, Spain
| | - Josep Redon
- Clinic Hospital. University of Valencia, 46010, València, Spain. .,INCLIVA Research Institute, 46010, Valencia, Spain. .,CIBERObn, Institute of Health Carlos III, Madrid, Spain.
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11
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Systemic Inflammatory Response Syndrome in Patients Hospitalized for Acute Decompensation of Cirrhosis. Can J Gastroenterol Hepatol 2021; 2021:5581587. [PMID: 33987144 PMCID: PMC8093053 DOI: 10.1155/2021/5581587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although recently challenged, systemic inflammatory response syndrome (SIRS) criteria are still commonly used in daily practice to define sepsis. However, several factors in liver cirrhosis may negatively impact its prognostic ability. Goals. To investigate the factors associated with the presence of SIRS, the characteristics of SIRS related to infection, and its prognostic value among patients hospitalized for acute decompensation of cirrhosis. Study. In this cohort study from two tertiary hospitals, 543 patients were followed up, up to 90 days. Data collection, including the prognostic models, was within 48 hours of admission. RESULTS SIRS was present in 42.7% of the sample and was independently associated with upper gastrointestinal bleeding (UGB), ACLF, infection, and negatively related to beta-blockers. SIRS was associated with mortality in univariate analysis, but not in multiple Cox regression analysis. The Kaplan-Meier survival probability of patients without SIRS was 73.0% and for those with SIRS was 64.7%. The presence of SIRS was not significantly associated with mortality when considering patients with or without infection, separately. Infection in SIRS patients was independently associated with Child-Pugh C and inversely related to UGB. Among subjects with SIRS, mortality was independently related to the presence of infection, ACLF, and Child-Pugh C. CONCLUSIONS SIRS was common in hospitalized patients with cirrhosis and was of no prognostic value, even in the presence of infection.
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12
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Update on diagnosis and management of sepsis in cirrhosis: Current advances. World J Hepatol 2020; 12:451-474. [PMID: 32952873 PMCID: PMC7475781 DOI: 10.4254/wjh.v12.i8.451] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/28/2020] [Accepted: 06/27/2020] [Indexed: 02/06/2023] Open
Abstract
Sepsis and septic shock are catastrophic disease entities that portend high mortality in patients with cirrhosis. In cirrhosis, hemodynamic perturbations, immune dysregulation, and persistent systemic inflammation with altered gut microbiota in the background of portal hypertension enhance the risk of infections and resistance to antimicrobials. Patients with cirrhosis develop recurrent life-threatening infections that progress to multiple organ failure. The definition, pathophysiology, and treatment options for sepsis have been ever evolving. In this exhaustive review, we discuss novel advances in the understanding of sepsis, describe current and future biomarkers and scoring systems for sepsis, and delineate newer modalities and adjuvant therapies for the treatment of sepsis from existing literature to extrapolate the same concerning the management of sepsis in cirrhosis. We also provide insights into the role of gut microbiota in initiation and progression of sepsis and finally, propose a treatment algorithm for management of sepsis in patients with cirrhosis.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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13
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Qin W, Zhang X, Yang L, Li Y, Yang S, Li X, Hu W. Predictive value of the sequential organ failure assessment (SOFA) score for prognosis in patients with severe acute ischemic stroke: a retrospective study. J Int Med Res 2020; 48:300060520950103. [PMID: 32865055 PMCID: PMC7469749 DOI: 10.1177/0300060520950103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/24/2020] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To identify the risk factors for early death and determine the predictive value of the sequential organ failure assessment (SOFA) score for prognosis of severe acute ischemic stroke (AIS). METHODS A total of 110 patients with severe AIS were enrolled and divided into the non-survivor (n = 34) and survivor groups (n = 76). Logistic regression analysis was conducted to identify risk factors for early death, while the receiver operator characteristic (ROC) curve was used to determine the predictive effect of the SOFA score on prognosis. RESULTS Logistic regression analysis showed that urinary tract infection (odds ratio [OR] = 17.364, 95% confidence interval [CI]: 1.903-158.427), mechanical ventilation (OR = 1.754, 95% CI: 1.648-2.219), and osmotic therapy (OR = 2.835, 95% CI: 1.871-5.102) were significantly correlated with early death of severe AIS. ROC curve analysis of the area under the curve after hospitalization showed that the maximum SOFA and ΔSOFA scores exceeded 0.7. CONCLUSION Our study shows that urinary tract infection, mechanical ventilation, and osmotic therapy are risk factors for early death of severe AIS. The SOFA score has good predictive value for prognosis of severe AIS. These findings may provide a guideline for improving clinical outcome.
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Affiliation(s)
- Wei Qin
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiaoyu Zhang
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Lei Yang
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yue Li
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shuna Yang
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xuanting Li
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wenli Hu
- Department of Neurology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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