The effects of cause of death classification on prognostic assessment of patients with pulmonary embolism

BACKGROUND

Although previous studies have provided evidence that the majority of deaths following an acute pulmonary embolism (PE) directly relate to the PE, more recent registries and cohort studies suggest otherwise.

METHODS

We assessed the cause of death during the first 30 days after the diagnosis of acute symptomatic PE in a consecutive series of patients. We also assessed the prognostic characteristics of the simplified Pulmonary Embolism Severity Index (sPESI) and cardiac troponin I (cTnI) obtained at the time of PE diagnosis.

RESULTS

During the first 30 days after diagnosis, 127 of the 1291 patients died (9.8%; 95% confidence interval [CI], 8.2-11.5). Sixty patients (4.6%; 95% CI, 3.5-5.8) died from definite or possible PE, and 67 (5.2%; 95% CI, 4.0-6.4) died from other causes (cancer 25, infection 18, hemorrhage 7, heart failure 7, chronic obstructive pulmonary disease 5, renal failure 1, seizures 1, unknown 3). The sPESI predicted all-cause (odds ratio [OR], 5.97; 95% CI, 1.74-20.54; P < 0.01) and PE-associated mortality (OR, 8.79; 95% CI, 1.12-68.79; P = 0.04). cTnI only predicted PE-associated mortality (adjusted OR, 2.39; 95% CI, 1.25-4.57; P < 0.01). For all-cause mortality, the sPESI low-risk strata had a negative predictive value of 98.8% (95% CI, 97.4-100) in comparison with 91.3% (95% CI, 88.9-93.6) for the cTnI.

CONCLUSIONS

Within the first 30 days after the diagnosis of acute symptomatic PE, death due to PE and death due to other causes occur in a similar proportion of patients. As cTnI only predicted PE-associated mortality, low-risk sPESI had a higher negative predictive value for all-cause mortality compared with cTnI.

Follow-up with Telemedicine in Early Discharge for COPD Exacerbations: Randomized Clinical Trial (TELEMEDCOPD-Trial)

The results reported by different studies on telemonitoring in patients with chronic obstructive pulmonary disease (COPD) have been contradictory, without showing clear benefits to date. The objective of this study was to ascertain whether an early discharge and home hospitalization telehealth program for patients with COPD exacerbation is as effective as and more efficient than a traditional early discharge and home hospitalization program. A prospective experimental non-inferiority study, randomized into two groups (telemedicine/control) was conducted. The telemedicine group underwent monitoring and was required to transmit data on vital constants and ECGs twice per day, with a subsequent telephone call and 2 home visits by healthcare staff (intermediate and at discharge). The control group received daily visits. The main variable was time until first exacerbation. The secondary variables were: number of exacerbations; use of healthcare resources; satisfaction; quality of life; anxiety-depression; and therapeutic adherence, measured at one and 6 months of hospital discharge. A total of 116 patients were randomized (58 to each group) without significant differences in baseline characteristics or time until first exacerbation, i.e. median 48 days (pp. 25-75:23-120) in the control group, and 47 days (pp. 25-75:19-102) in the intervention group; p = 0.52). A significant decrease in the number of visits was observed in the intervention versus the control group, 3.8 ± 1 vs 5.1 ± 2(p = 0.001), without significant differences in the number of exacerbations. In conclusion follow-up via a telemedicine program in early discharge after hospitalization is as effective as conventional home follow up, being the cost of either strategy not significantly different.

Depression Identification Using EEG Signals via a Hybrid of LSTM and Spiking Neural Networks

Depression severity can be classified into distinct phases based on the Beck depression inventory (BDI) test scores, a subjective questionnaire. However, quantitative assessment of depression may be attained through the examination and categorization of electroencephalography (EEG) signals. Spiking neural networks (SNNs), as the third generation of neural networks, incorporate biologically realistic algorithms, making them ideal for mimicking internal brain activities while processing EEG signals. This study introduces a novel framework that for the first time, combines an SNN architecture and a long short-term memory (LSTM) structure to model the brain's underlying structures during different stages of depression and effectively classify individual depression levels using raw EEG signals. By employing a brain-inspired SNN model, our research provides fresh perspectives and advances knowledge of the neurological mechanisms underlying different levels of depression. The methodology employed in this study includes the utilization of the synaptic time dependent plasticity (STDP) learning rule within a 3-dimensional brain-template structured SNN model. Furthermore, it encompasses the tasks of classifying and predicting individual outcomes, visually representing the structural alterations in the brain linked to the anticipated outcomes, and offering interpretations of the findings. Notably, our method achieves exceptional accuracy in classification, with average rates of 98% and 96% for eyes-closed and eyes-open states, respectively. These results significantly outperform state-of-the-art deep learning methods.

Impact of Perioperative Serum Sodium Levels on Outcomes Following Living Donor Liver Transplantation

Background & objectives

Preoperative hyponatremia has been shown to be associated with poor outcomes post-liver transplantation. We analyzed the impact of preoperative hyponatremia and perioperative sodium (Na) changes on outcomes following adult living donor liver transplantation.

Methods

After obtaining clearance from Institutional ethical Committee, a retrospective review of electronic database and medical records of all adult patients who underwent LDLT between January 2019 and September 2022 was done and relevant perioperative data were collected.

Results

The study cohort of 520 recipients was divided into four groups based on preoperative serum Na levels in mmol/L; 12 patients (2.3%) in Group A (<125); 66 patients (12.6%) in Group B (125-129); 216 patients (41.5%) in Group C (130-135) and 226 patients (43.4%) in Group D (136-145). MELD score, preoperative AKI, SBP, intraoperative ascites volume, volume of packed blood cells (PRC), other blood products and 25% albumin were significantly associated with the degree of hyponatremia. No other outcomes including mortality was associated any grade of hyponatremia. The delta sodium on postoperative day 1 was largest in Group A. The level of Na rise post-transplant on POD1 had an inverse correlation with preoperative Na levels [ r (520) -0.6, P < 0.001]. High delta sodium was not associated with neurological complications in this cohort. Group A patients had higher incidence of postoperative AKI requiring dialysis followed by groups B, C and D. Eighty-six (16.5%) patients had large delta-Na of >10 mmol/L. On univariate analysis, low pretransplant Na (<130mEq/L), preoperative AKI, SBP, higher MELD and ascitic volumes, intraoperative transfusions of PRC, blood products and 25% albumin, early allograft dysfunction and need for dialysis, were associated with larger delta-Na. On multivariate analysis, preoperative Na levels ≤130 mmol/L, intraoperative ascites and PRC transfusion were found to be independent risk factors for a large delta-Na.

Conclusion

Hyponatremia, being a factor associated with liver disease, might not by itself contribute to poor survival when the deleterious effects of large delta changes can be avoided. The results from this study reinforces the fact that with a cautious perioperative approach, patients with hyponatremia can be transplanted safely in LDLT settings.

Home environment and asthma in school children from the Edirne region in Turkey

Studies have shown that environmental factors contribute to the development of asthma. Hence, we investigated the relation between current asthma and indoor environmental factors such as exposure to pets, tobacco smoke, home dampness, number of people living in home, and stuffed toys in child's bedroom in a questionnaire based study in primary school children aged 6 to 12 years living in Edirne (Turkey). In a random sample of 4 primary schools, questionnaires were completed by parents of 1000 children. Following the evaluation of 682 of these, 85 were selected as cases of asthma of which 24 were diagnosed by a physician. When required certain laboratory tests were also performed in order to confirm the diagnosis. Logistic regression was used to investigate the associations between asthma and potential risk factors. In logistic regression analyses, the following factors were associated with asthma. Dampness in the house [(odd's ratio (O.R) = 2.61; 95% CI 1.13 to 6.81), stuffed toys in the child's bedroom (O.R = 2.18; 95% CI 1.27 to 3.74), and the crowding index (O.R = 2.73; 95% CI 1.08 to 6.82)]. In conclusion, it was found that presence of asthma was significantly associated with the presence of dampness in the house, and stuffed toys in the child's bedroom. Asthma can be prevented by improvement of the indoor environment. Therefore providing education to high-risk populations for avoidance of these risk factors is particularly important.

Effect of Preoperative Sarcopenia, Malnutrition and Functional status on Postoperative Morbidity Following Liver Transplantation

INTRODUCTION

The effect of sarcopenia, malnutrition, and functional status on immediate post liver transplantation outcome is not well established. Most studies on sarcopenia are related to 1 and 3-year mortality. Studies evaluating the effect of malnutrition are at least a decade old.

PROJECT AIMS

We evaluated the effect of preoperative sarcopenia, malnutrition, and functional status on postoperative length of hospital and ICU stay, incidence of complications, and mortality.

DESIGN

In this prospective study conducted on living donor liver transplant recipients, sarcopenia and malnutrition were identified using the psoas muscle thickness to height and the Royal Free Hospital- Nutritional Prioritizing Tool respectively. The Eastern Cooperative Oncology Group performance status score was noted. Postoperatively, length-of-hospital stay, ICU stay, duration of mechanical ventilation and incidence of postoperative complications were noted.

RESULTS

Hospital and ICU length of stay, and duration of mechanical ventilation were greater in sarcopenic versus non-sarcopenic patients (35.9 (14.6) versus 26.7 (10.7) days, P  =  0.02; 12.9 (4.8) versus 9.6 (3.8) days, P  =  0.02 and 8 [5,23] versus 5 [4,7] days, P  =  0.01 respectively). The incidence of acute kidney injury was higher in patients with sarcopenia (53.3% vs 19.4%, P  =  0.02). Patients with malnutrition and repeated hospitalizations had higher ICU stays but hospital length of stay duration of mechanical ventilation or the incidence of postoperative complications were not affected. The Eastern Cooperative Oncology Group score did not affect postoperative outcome.

CONCLUSION

In living donor liver transplant recipients, sarcopenia increased hospital and ICU stays, and duration of mechanical ventilation postoperatively. Malnutrition increased ICU stays.

Administration of magnesium sulphate does not prevent post-reperfusion syndrome but is necessary during living donor liver transplantation

Severe hemodynamic instability is observed during portal vein de-clamping in the form of post-reperfusion syndrome in liver transplantation. The protective effect of magnesium on inflammation and ischemia-reperfusion injuries of various organs is evident, but its role in the prevention of post-reperfusion syndrome in liver transplantation is not clear. We investigated the effect of magnesium sulphate on the incidence of post-reperfusion syndrome during living donor liver transplantation. The secondary outcomes were the requirement of vasopressor boluses and levels of serum magnesium, lactate and serum C-reactive protein. Seventy living donor liver transplant recipients were randomized into a magnesium (M) group (n = 35) or normal saline (N) group (n = 35). The patients in group M received 35 mg/kg of magnesium sulphate, 30 minutes after the beginning of the anhepatic phase, and patients in group N received normal saline. The incidence of post-reperfusion syndrome in group M and group N was 34.29% and 40%, respectively, with no significant difference. The requirement for rescue vasopressor boluses and levels of C-reactive protein and lactate were also comparable between the two groups. However, the incidence of hypomagnesemia at the end of surgery was significantly higher in group N (37.1% vs. 14.28%, p = 0.027). Magnesium does not appear to prevent post-reperfusion syndrome. However, hypomagnesemia is more frequently seen during liver transplantation. Hence, serum magnesium should be routinely monitored and administered during liver transplantation.

Early Prediction of Acute Kidney Injury in Living Donor Liver Transplantation by Serum Cystatin C Concentration at the End of the Surgery

INTRODUCTION

Acute kidney injury (AKI) is a prevalent complication of liver transplantation, leading to prolonged hospital or intensive care unit stay and significant morbidity. Recently, biomarkers such as neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C have been investigated for their potential role in the early detection of AKI in liver transplantation patients.

METHOD

Our study comprised 60 patients with end-stage liver disease undergoing living donor liver transplantation. Based on the postoperative development of AKI, the patients were categorised into two groups: the AKI group comprising 22 patients and the non-AKI group comprising 38 patients. Serum cystatin C and urine NGAL levels were measured twice: immediately after induction of anaesthesia (baseline) and at the end of the surgery.

RESULTS

The overall incidence of AKI was 36.66%. The mean cystatin C level measured at the end of the surgery was significantly higher in the AKI group (1.12 ± 0.40 mg/L) than in the non-AKI group (0.82 ± 0.27 mg/L) [P = .001]. The receiver operating characteristic curve for the postoperative cystatin C biomarker demonstrated a significant difference between the AKI and non-AKI groups [area under the curve: 0.71, P = .007]. However, baseline cystatin C and urine NGAL levels did not significantly differ between the groups.

CONCLUSION

Cystatin C levels measured at the end of the surgery showed a better predictive value and higher accuracy in identifying post-liver transplantation patients with AKI than baseline cystatin C and urine NGAL.