Risk factors for long-term mortality in patients admitted with severe infection.

BACKGROUND: Severe infection is a main cause of mortality. We aim to describe risk factors for long-term mortality among inpatients with severe infection. METHODS: Prospective cohort study in a 600-bed university hospital in Portugal including all patients with severe infection admitted into intensive care, medical, surgical, hematology and nephrology wards over one-year period. The outcome of interest was 5-year mortality following infection. Variables of patient background and infectious episode were studied in association with the main outcome through multiple logistic regression. There were 1013 patients included in the study. Hospital and 5-year mortality rates were 14 and 37%, respectively. RESULTS: Two different models were developed (with and without acute-illness severity scores) and factors independently associated with 5-year mortality were [adjusted odds ratio (95% confidence interval)]: age = 1.03 per year (1.02-1.04), cancer = 4.36 (1.65-11.53), no comorbidities = 0.4 (0.26-0.62), Karnovsky Index < 70 = 2.25 (1.48-3.40), SAPS (Simplified Acute Physiology Score) II = 1.05 per point (1.03-1.07), positive blood cultures = 1.57 (1.01-2.44) and infection by an ESKAPE pathogen (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeroginosa and Enterobacter species) = 1.61 (1.00- 2.60); and in the second model [without SAPS II and SOFA (Sequential Organ Failure Assessment) scores]: age = 1.04 per year (1.03-1.05), cancer = 5.93 (2.26-15.51), chronic haematologic disease = 2.37 (1.14-4.93), no comorbidities = 0.45 (0.29-0.69), Karnovsky Index< 70 = 2.32 (1.54- 3.50), septic shock [reference is infection without SIRS (Systemic Inflammatory Response Syndrome)] = 3.77 (1.80-7.89) and infection by an ESKAPE pathogen = 1.61 (1.00-2.60). Both models presented a good discrimination power with an AU-ROC curve (95% CI) of 0.81 (0.77-0.84) for model 1 and 0.80 (0.76-0.83) for model 2. If only patients that survived hospital admission are included in the model, variables retained are: age = 1.03 per year (1.02-1.05), cancer = 4.69 (1.71-12.83), chronic respiratory disease = 2.27 (1.09-4.69), diabetes mellitus = 1.65 (1.06-2.56), Karnovsky Index < 70 = 2.50 (1.63-3.83) and positive blood cultures = 1.66 (1.04-2.64) with an AU-ROC curve of 0.77 (0.73-0.81). CONCLUSIONS: Age, previous comorbidities, and functional status and infection by an ESKAPE pathogen were consistently associated with long-term prognosis. This information may help in the discussion of individual prognosis and clinical decision-making.

Survival Predictors in Liver Transplantation: Time-Varying Effect of Red Blood Cell Transfusion.

BACKGROUND: Many attempts have been undertaken to better predict outcome after liver transplantation. The aim of this study was to identify the pre- and intraoperative variables that may influence the survival after liver transplantation, at a single institution. METHODS: Anesthetic records from 543 consecutive patients who underwent liver transplantation from June 2006 to June 2014 were reviewed in this retrospective study. Patients undergoing retransplantation were excluded from the analysis, as were patients with familial amyloid polyneuropathy. Preoperative variables studied were age, sex, Model for End-Stage Liver Disease score, primary diagnosis, cold ischemia time, preoperative international normalized ratio, serum albumin, and and hemoglobin levels. Intraoperative variables included were norepinephrine consumption, blood loss, red blood cell transfusion, and surgical time. Variables significant in the univariate analysis with a P value of <.2 were included in a multivariate Cox regression model. RESULTS: Only red blood cell transfusion (hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.04-1.29) and female sex (HR, 1.71; 95% CI, 1.10-2.65) were identified as significant independent predictors for survival after liver transplantation. Because of proportionality assumption violation, the multivariate Cox regression model was subsequently upgraded by adding a time-varying interaction between red blood cell transfusion and time since liver transplantation. As a result, we found that at 3 months after liver transplantation, the rate of dying increased 14% (95% CI, 2%-26%) for each unit transfused, and at 6 months it increased 12% (95% CI, 0.3%-24%). CONCLUSIONS: Red blood cell transfusion ceased to influence survival from 1 year onward.

Perioperative Predictors of Survival After Liver Transplantation for Familial Amyloid Polyneuropathy in a Portuguese Center.

BACKGROUND: Liver transplantation (LT) has been the treatment of choice to halt the progression of familial amyloid polyneuropathy (FAP). Few studies have identified prognostic factors for post-LT survival in FAP. Our aim was to assess survival rate and to identify independent factors for survival after LT. METHODS: This retrospective cohort study of FAP patients transplanted for the first time analyzed 116 transplantations from 2006 to 2014. The median follow-up period was 45.5 months. RESULTS: The overall survival rates at 1 month, 1 year, and 5 years were 89%, 82% and 79%, respectively. On multivariate analysis, only number of red blood cell (RBC) units transfused during surgery, operation time, and body mass index were independent prognostic factors for patient survival. Only 30% of patients were transfused during surgery, and, in these, each RBC unit transfused increased mortality by 53%. The operation time increased mortality by 20% for every 15 minutes of surgery. CONCLUSIONS: This study suggests that operation time and RBC transfused are predominant factors affecting post-LT survival in our FAP patients.

[Successful pregnancy in a severely hypoxemic patient with pulmonary alveolar proteinosis]. / Gravidez de termo em doente com proteinose alveolar e insuficiência respiratória grave.

Pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by abnormal accumulation of a lipoproteinaceous material in the alveoli, which may lead to respiratory failure and has an associated high risk for infections. The mainstay treatment for PAP is whole lung lavage. A pregnant woman, previously diagnosed with primary PAP, the most common form of PAP, was admitted with dyspnea and worsening respiratory function. In one month period, a whole-lung bronchopulmonary lavage was performed twice, with clinical and functional improvement. Pregnancy was carried to term and a healthy baby was delivered. The mechanisms of respiratory impairment are discussed as well as treatment options and response.

[Embolization--a new concept in the treatment of esophageal varices (late results)]. / Embolização--uma nova conceituação no tratamento das varizes esofágicas (resultados tardios).

Although since 1978 we have been applying this new technique, we awaited the late results to evaluate with security the value of its application. As we have previously described in a short communication, in 1979, to embolizate the esophageal bleeding varices, we use a laparotomic approach through the right gastric vein to inject the embolizating material. After five years applying this technique, the results confirmed its efficacy.