Juan Felipe Lucena

Liver Transplant Recipients Older Than 60 Years Have Lower Survival and Higher Incidence of Malignancy

Older age is not considered a contraindication for liver transplantation, but age‐related morbidity may be a cause of mortality. Survival and the incidence of the main post‐transplant complications were assessed in 111 adult liver transplant recipients. They were divided in two groups according to their age (patients younger than 60 years, n=54; patients older than 60 years, n=57) and both groups were compared. Older patients were more frequently transplanted for hepatitis C (p= 0.03) and hepatocellular carcinoma (p= 0.05) and their liver disease was less advanced (Child‐Pugh and MELD scores were significantly lower; p=0.004 and p=0.05, respectively). After transplantation, older patients had a significantly lower survival (p=0.02). Higher age was independently associated with mortality (hazard ratio for each 10‐year increase: 2.1; 95% confidence interval: 1.1‐ 4.0; p=0.02). The incidence of de novo neoplasia and nonskin neoplasia were higher in older patients (p=0.02 and p =0.007, respectively). Malignancy was the cause of death in one patient younger than 60 years and in 12 patients older than 60 years (p =0.002). In multivariate analysis, a higher age and smoking were independently associated with a higher risk of dying of de novo neoplasia. In conclusion, older liver transplant recipients have a significantly lower survival than younger patients. Malignancy is responsible for this decreased survival.

Performance of SAPS II and SAPS 3 in Intermediate Care

Objective The efficacy and reliability of prognostic scores has been described extensively for intensive care, but their role for predicting mortality in intermediate care patients is uncertain. To provide more information in this field, we have analyzed the performance of the Simplified Acute Physiology Score (SAPS) II and SAPS 3 in a single center intermediate care unit (ImCU). Materials and Methods Cohort study with prospectively collected data from all patients admitted to a single center ImCU in Pamplona, Spain, from April 2006 to April 2012. The SAPS II and SAPS 3 scores with respective predicted mortality rates were calculated according to standard coefficients. Discrimination was evaluated by calculating the area under receiver operating characteristic curve (AUROC) and calibration with the Hosmer-Lemeshow goodness of fit test. Standardized mortality ratios (SMR) with 95% confidence interval (95% CI) were calculated for each model. Results The study included 607 patients. The observed in-hospital mortality was 20.1% resulting in a SMR of 0.87 (95% CI 0.73-1.04) for SAPS II and 0.56 (95% CI 0.47-0.67) for SAPS 3. Both scores showed acceptable discrimination, with an AUROC of 0.76 (95% CI 0.71-0.80) for SAPS II and 0.75 (95% CI 0.71- 0.80) for SAPS 3. Calibration curves showed similar performance based on Hosmer-Lemeshow goodness of fit C-test: (X2=12.9, p=0.113) for SAPS II and (X2=4.07, p=0.851) for SAPS 3. Conclusions Although both scores overpredicted mortality, SAPS II showed better discrimination for patients admitted to ImCU in terms of SMR.

Results of a retrospective observational study of intermediate care staffed by hospitalists: Impact on mortality, co‐management, and teaching

BACKGROUND Hospitalized patients are complex and institutions have to face the high cost of critical care and the limited resources of the ward. Intermediate care appears as an attractive strategy to provide rational care according to patient needs. It is an interesting scenario to expand co-management and teaching. STUDY DESIGN Retrospective observational study. SETTING Intermediate care unit (ImCU) of a single academic hospital. PATIENTS AND METHODS 456 patients admitted from April 2006 to April 2010 were included in the study. Demographics, admission physiologic parameters and in-hospital mortality were recorded. We used the Simplified Acute Physiology Score II (SAPS II) as prognostic score system. Co-management with medical and surgical teams, and the number of training residents were evaluated. RESULTS In-hospital mortality was 20.6%, whereas the expected mortality was 23.2% based on SAPS II score. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (Rho = 1.0, p < 0.001). Co-management was performed with several medical and surgical teams, with an increase in perioperative comanagement of 22.7% (p = 0.014). The number of training residents in ImCU increased from 4.3% to 30.4% (p = 0.002) CONCLUSIONS An ImCU led by hospitalists showed encouraging results regarding patient survival and SAPS II is an useful tool for prognostic evaluation in this population. Intermediate care serves as an expansion of role for hospitalists; and clinicians, trainees and patients may benefit from co-management and teaching opportunities at this unique level of care.

Design and Performance of a New Severity Score for Intermediate Care

Background Application of illness-severity scores in Intermediate Care Units (ImCU) shows conflicting results. The aim of the study is to design a severity-of-illness score for patients admitted to an ImCU. Methods We performed a retrospective observational study in a single academic medical centre in Pamplona, Spain. Demographics, past medical history, reasons for admission, physiological parameters at admission and during the first 24 hours of ImCU stay, laboratory variables and survival to hospital discharge were recorded. Logistic regression analysis was performed to identify variables for mortality prediction. Results A total of 743 patients were included. The final multivariable model (derivation cohort = 554 patients) contained only 9 variables obtained at admission to the ImCU: previous length of stay 7 days (6 points), health-care related infection (11), metastatic cancer (9), immunosuppressive therapy (6), Glasgow comma scale 12 (10), need of non-invasive ventilation (14), platelets 50000/mcL (9), urea 0.6 g/L (10) and bilirubin 4 mg/dL (9). The ImCU severity score (ImCUSS) is generated by summing the individual point values, and the formula for determining the expected in-hospital mortality risk is: eImCUSS points*0.099 – 4,111 / (1 + eImCUSS points*0.099 – 4,111). The model showed adequate calibration and discrimination. Performance of ImCUSS (validation cohort = 189 patients) was comparable to that of SAPS II and 3. Hosmer-Lemeshow goodness-of-fit C test was χ2 8.078 (p=0.326) and the area under receiver operating curve 0.802. Conclusions ImCUSS, specially designed for intermediate care, is based on easy to obtain variables at admission to ImCU. Additionally, it shows a notable performance in terms of calibration and mortality discrimination.

Mortality Prediction in Patients Undergoing Non-Invasive Ventilation in Intermediate Care

Background Intermediate Care Units (ImCU) have become an alternative scenario to perform Non-Invasive Ventilation (NIV). The limited number of prognostic studies in this population support the need of mortality prediction evaluation in this context. Objective The objective of this study is to analyze the performance of Simplified Acute Physiology Score (SAPS) II and 3 in patients undergoing NIV in an ImCU. Additionally, we searched for new variables that could be useful to customize these scores, in order to improve mortality prediction. Design Cohort study with prospectively collected data from all patients admitted to a single center ImCU who received NIV. The SAPS II and 3 scores with their respective predicted mortality rates were calculated. Discrimination and calibration were evaluated by calculating the area under the receiver operating characteristic curve (AUC) and with the Hosmer-Lemeshow goodness of fit test for the models, respectively. Binary logistic regression was used to identify new variables to customize the scores for mortality prediction in this setting. Patients The study included 241 patients consecutively admitted to an ImCU staffed by hospitalists from April 2006 to December 2013. Key Results The observed in-hospital mortality was 32.4% resulting in a Standardized Mortality Ratio (SMR) of 1.35 for SAPS II and 0.68 for SAPS 3. Mortality discrimination based on the AUC was 0.73 for SAPS II and 0.69 for SAPS 3. Customized models including immunosuppression, chronic obstructive pulmonary disease (COPD), acute pulmonary edema (APE), lactic acid, pCO2 and haemoglobin levels showed better discrimination than old scores with similar calibration power. Conclusions These results suggest that SAPS II and 3 should be customized with additional patient-risk factors to improve mortality prediction in patients undergoing NIV in intermediate care.

Enterococcal bloodstream infection. Design and validation of a mortality prediction rule.

To develop a prediction rule to describe the risk of death as a result of enterococcal bloodstream infection.

Renal Autotransplant for Subsequent Endovascular Exclusion of the Thoracoabdominal Aorta

In the last 20 years, endovascular procedures have radically altered the treatment of diseases of the aorta. The objective of endovascular treatment of dissections is to close the entry point to redirect blood flow toward the true lumen, thereby achieving thrombosis of the false lumen. In extensive chronic dissections that have evolved with the formation of a large aneurysm, the dissection is maintained from the end of the endoprosthesis due to multiple orifices, or reentries, that communicate with the lumens. In addition, one of the primary limitations of this technique is when the visceral arteries have disease involvement. In this report we present a case where, despite having treated the entire length of the descending thoracic aorta, the dissection was maintained distally, leading to progression of the diameter of the aneurysm. After reviewing the literature, and to the best of our knowledge, we describe the first case in which renal autotransplant was performed to allow for subsequent exclusion of the aorta at the thoracoabdominal level using a fenestrated endoprosthesis for the celiac trunk and the superior mesenteric artery.

Hospital mortality prediction for intermediate care patients: Assessing the generalizability of the Intermediate Care Unit Severity Score (IMCUSS)

Purpose: The Intermediate Care Unit Severity Score (IMCUSS) is an easy to calculate predictor of in‐hospital death, and the only such tool developed for patients in the intermediate care setting. We sought to examine its external validity. Materials and methods: Using data from patients admitted to the intermediate care unit (IMCU) of an urban academic medical center from July to December of 2012, model discrimination and calibration for predicting in‐hospital death were assessed using the area under the receiver operating characteristic (AUROC) and the Hosmer‐Lemeshow goodness‐of‐fit chi‐squared (HL GOF X2) test, respectively. The standardized mortality ratio (SMR) with 95% confidence intervals (95% CI) was also calculated. Results: The cohort included data from 628 unique admissions to the IMCU. Overall hospital mortality was 8.3%. The median IMCUSS was 10 (Interquartile Range: 0–16), with 229 (36%) patients having a score of zero. The AUROC for the IMCUSS was 0.72 (95% CI: 0.64–0.78), the HL GOF X2 = 30.7 (P < 0.001), and the SMR was 1.22 (95% CI: 0.91–1.60). Conclusions: The IMCUSS exhibited acceptable discrimination, poor calibration, and underestimated mortality. Other centers should assess the performance of the IMCUSS before adopting its use. HIGHLIGHTSIMCUs serve patients with care needs that exceed ward level resources, but do not require ICU care.Though prevalent, IMCUs have heterogeneous organizational models.A valid outcome prediction score would improve comparison of different IMCU models.The Intermediate Care Unit Severity Score (IMCUSS) was not transportable to our multipurpose IMCU.Despite acceptable discrimination, calibration was poor, especially when scores were low.

Lercanidipine-induced chylous ascites: Case report and literature review

Chylous ascites is a rare condition. The most frequent causes are lymphomas, solid malignancies, abdominal trauma and cirrhosis. Isolated case reports describe the relationship between calcium channel blockers (CCB) and chyloperitoneum. Lercanidipine is a third‐generation dihydropyridine with low rate of adverse events. We describe a case of lercanidipine‐induced chylous ascites.

Comment on “Retrospective evaluation of prognostic score performances in cirrhotic patients admitted to an intermediate care unit” by Benoît Dupont et al. [Digestive and Liver Disease 2015;47:675–81]

onflict of interest one declared. eral prognostic scores (SAPS II or SAPS 3) were globally higher in the Alegre et al. series whereas the values of liver specific prognostic scores were higher in our study. This data certainly illustrates that the Ci-pro score lacks from universality and is more adapted to situations of decompensated liver disease. Similarly, SAPS 3, although interesting in cases of ImCU admission for general complications as illustrated in Alegre et al.’s study [5], was of less interest in decompensated liver disease in our series. As explained in the discussion of the article [1], the weight of cirrhosis in the calculation of the score could underestimate the discriminating effect of the score in our population of decompensated liver disease, which could not be the case when the reason of the admission in ImCU is not a liver-related cause. Another explanation could come from a difference in the cause of the liver disease. In our study the vast majority of liver diseases (88%) were alcoholic. The cause of the liver disease is not reported by Alegre et al. [5] but we can suspect that the proportion of alcoholic liver diseases was less important. It is admitted that the cause of the liver disease can influence the natural history and prognosis of the cirrhosis and could certainly have influenced the results of these respective analyses [2]. Despite all these explanations, we believe that the relatively limited population (51 patients) in [5] cannot permit to conclude about the real performances of the different studied prognostic scores in cirrhotic patients admitted to ImCU. The population of