Contrast-enhanced CT and Acute Kidney Injury: Risk Stratification by Diabetic Status and Kidney Function.

Background Diabetes mellitus may be associated with an increased likelihood of CT contrast material-induced acute kidney injury (CI-AKI), but this has not been studied in a large sample with and without kidney dysfunction. Purpose To investigate whether diabetic status and estimated glomerular filtration rate (eGFR) are associated with the likelihood of acute kidney injury (AKI) following CT contrast material administration. Materials and Methods This retrospective multicenter study included patients from two academic medical centers and three regional hospitals who underwent contrast-enhanced CT (CECT) or noncontrast CT between January 2012 and December 2019. Patients were stratified according to eGFR and diabetic status, and subgroup-specific propensity score analyses were performed. The association between contrast material exposure and CI-AKI was estimated with use of overlap propensity score-weighted generalized regression models. Results Among the 75 328 patients (mean age, 66 years ± 17 [SD]; 44 389 men; 41 277 CECT scans; 34 051 noncontrast CT scans), CI-AKI was more likely in patients with an eGFR of 30-44 mL/min/1.73 m2 (odds ratio [OR], 1.34; P < .001) or less than 30 mL/min/1.73 m2 (OR, 1.78; P < .001). Subgroup analyses revealed higher odds of CI-AKI among patients with an eGFR less than 30 mL/min/1.73 m2, with or without diabetes (OR, 2.12 and 1.62; P = .001 and .003, respectively), when they underwent CECT compared with noncontrast CT. Among patients with an eGFR of 30-44 mL/min/1.73 m2, the odds of CI-AKI were higher only in those with diabetes (OR, 1.83; P = .003). Patients with an eGFR less than 30 mL/min/1.73 m2 and diabetes had higher odds of 30-day dialysis (OR, 1.92; P = .005). Conclusion Compared with noncontrast CT, CECT was associated with higher odds of AKI in patients with an eGFR of less than 30 mL/min/1.73 m2 and in patients with diabetes with an eGFR of 30-44 mL/min/1.73 m2; higher odds of 30-day dialysis were observed only in patients with diabetes with an eGFR less than 30 mL/min/1.73 m2. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Davenport in this issue.

Fetal-neonatal and maternal outcomes in women with Sjögren syndrome: a population-based registry linkage study.

OBJECTIVE: To provide better preconceptional and prenatal counselling to patients with sjögren syndrome (SS). METHODS: In total, 2 100 143 pregnancies between 2004 and 2014 were identified in the Taiwan National Health Insurance database and birth registry. The maternal history of SS was ascertained, and data were compared between pregnant women with and without SS. We assessed the odds ratios and 95% CIs of fetal-neonatal and maternal outcomes. RESULTS: There were 449 pregnancies in women with SS and 2 099 694 pregnancies in women without SS. The risks of still birth [odds ratio (OR) = 2.14, 95% CI = 1.01, 4.55], low birth weight (<2500 g, OR = 2.53, 95% CI = 1.92, 3.33), small for gestational age (OR = 2.03, 95% CI = 1.57, 2.03) and fetal distress (OR = 1.72, 95% CI = 1.2, 2.45) as well as maternal risks of pulmonary oedema (OR = 11.64, 95% CI = 1.62, 83.48), shock (OR = 6.07, 95% CI = 1.51, 24.3) and respiratory distress (OR = 5.61, 95% CI = 1.39, 22.6) were higher in the SS group than in the non-SS group. CONCLUSION: Women with SS have significant risks of adverse fetal-neonatal and maternal outcomes and must undergo prenatal counselling to understand the risks involved before conception.

Comparison of the diagnostic accuracy of monocyte distribution width and procalcitonin in sepsis cases in the emergency department: a prospective cohort study.

BACKGROUND: Early diagnosis and treatment of patients with sepsis reduce mortality significantly. In terms of exploring new diagnostic tools of sepsis, monocyte distribution width (MDW), as part of the white blood cell (WBC) differential count, was first reported in 2017. MDW greater than 20 and abnormal WBC count together provided a satisfactory accuracy and was proposed as a novel diagnostic tool of sepsis. This study aimed to compare MDW and procalcitonin (PCT)'s diagnostic accuracy on sepsis in the emergency department. METHODS: This was a single-center prospective cohort study. Laboratory examinations including complete blood cell and differentiation count (CBC/DC), MDW, PCT were obtained while arriving at the ED. We divided patients into non-infection, infection without systemic inflammatory response syndrome (SIRS), infection with SIRS, and sepsis-3 groups. This study's primary outcome is the sensitivity and specificity of MDW, PCT, and MDW + WBC in differentiating septic and non-septic patients. In addition, the cut-off value for MDW was established to maximize sensitivity at an optimal level of specificity. RESULTS: From May 2019 to September 2020, 402 patients were enrolled for data analysis. Patient number in each group was: non-infection 64 (15.9%), infection without SIRS 82 (20.4%), infection with SIRS 202 (50.2%), sepsis-3 15 (7.6%). The AUC of MDW, PCT, and MDW + WBC to predict infection with SIRS was 0.753, 0.704, and 0.784, respectively (p < 0.01). The sensitivity, specificity, PPV, and NPV of MDW using 20 as the cutoff were 86.4%, 54.2%, 76.4%, and 70%, compared to 32.9%, 88%, 82.5%, and 43.4% using 0.5 ng/mL as the PCT cutoff value. On combing MDW and WBC count, the sensitivity and NPV further increased to 93.4% and 80.3%, respectively. In terms of predicting sepsis-3, the AUC of MDW, PCT, and MDW + WBC was 0.72, 0.73, and 0.70, respectively. MDW, using 20 as cutoff, exhibited sensitivity, specificity, PPV, and NPV of 90.6%, 37.1%, 18.7%, and 96.1%, respectively, compared to 49.1%, 78.6%, 26.8%, and 90.6% when 0.5 ng/mL PCT was used as cutoff. CONCLUSIONS: In conclusion, MDW is a more sensitive biomarker than PCT in predicting infection-related SIRS and sepsis-3 in the ED. MDW < 20 shows a higher NPV to exclude sepsis-3. Combining MDW and WBC count further improves the accuracy in predicting infection with SIRS but not sepsis-3. Trial registration The study was retrospectively registered to the ClinicalTrial.gov (NCT04322942) on March 26th, 2020.

Intravenous CT Contrast Media and Acute Kidney Injury: A Multicenter Emergency Department-based Study.

Background Although the historical risk of acute kidney injury (AKI) after intravenous administration of contrast media might be overstated, the risk in patients with impaired kidney function remains a concern. Purpose To investigate whether intravenous contrast media administration during CT is associated with a higher risk of AKI and further hemodialysis compared with the risk in patients undergoing unenhanced CT. Materials and Methods This retrospective study evaluated patients who underwent contrast-enhanced or unenhanced CT in five Taiwanese emergency departments between 2009 and 2016. The outcomes were AKI within 48-72 hours after CT, AKI within 48 hours to 1 week after CT, or further hemodialysis within 1 month after CT. The associations between contrast media exposure and outcome were estimated by using an overlap propensity score weighted generalized regression model. Subgroup analyses were performed according to the estimated glomerular filtration rate (eGFR). Results The study included 68 687 patients (median age, 68 years; interquartile range, 53-74 years; 39 995 men) with (n = 31 103) or without (n = 37 584) exposure to contrast media. After propensity score weighting, contrast media exposure was associated with higher risk of AKI within 48-72 hours after CT (odds ratio [OR], 1.16; 95% CI: 1.04, 1.29; P = .007) but no significant risk at 48 hours to 1 week after CT (OR, 1.00; 95% CI: 0.93, 1.08; P = .90). Among patients with eGFR less than 30 mL/min/1.73 m2, exposure to contrast media was associated with a higher AKI risk (48-72 hours after CT: OR, 1.36; 95% CI: 1.09, 1.70; P = .007) (48 hours-1 week after CT: OR, 1.49; 95% CI: 1.27, 1.74; P < .001) and a higher risk of hemodialysis (OR, 1.36; 95% CI: 1.09, 1.70; P = .008). For patients with eGFR greater than 45 mL/min/1.73.m2, contrast media exposure was not associated with higher AKI risk (P > .05). Conclusion Contrast-enhanced CT was associated with higher risk of acute kidney injury and further hemodialysis among Taiwanese patients with an estimated glomerular filtration rate (eGFR) of less than 30 mL/min/1.73 m2 but not those with an eGFR of more than 45 mL/min/1.73 m2. © RSNA, 2021 Online supplemental material is available for this article.

Incidence of intoxication events and patient outcomes in Taiwan: A nationwide population-based observational study.

BACKGROUND: Intoxicated patients were frequently managed in the emergency departments (ED) with few studies at national level. The study aimed to reveal the incidence, outcomes of intoxications and trend in Taiwan. METHODS: Adults admitted to an ED due to an intoxication event between 2006 and 2013 were identified using the Taiwan National Health Insurance Research Database. The rate of intoxication and severe intoxication events, mortality rate, hospital length of stay (LOS), and daily medical costs of these patients were analyzed. Changes over time were analyzed using Joinpoint models. Multivariable generalized regressions with GEE were used to assess the effect of sex, age, and presence of prior psychiatric illness. RESULTS: A total of 20,371 ED admissions due to intoxication events were identified during the study period, and the incidence decreased with annual percentage change of 4.7% from 2006 to 2013. The mortality rate, hospital LOS, and daily medical costs were not decreased over time. Males and geriatric patients had more severe intoxication events, greater mortality rates, and greater daily medical costs. Patients with psychiatric illnesses had higher mortality rates and a longer hospital LOS, but lower daily medical expenses. CONCLUSION: From 2006 to 2013, there was a decline in the incidence of ED admission for intoxication events in Taiwan. Males, geriatric patients, and those with psychiatric illnesses had greater risks for severe intoxication and mortality.

Prognostic accuracy of SIRS criteria and qSOFA score for in-hospital mortality among influenza patients in the emergency department.

BACKGROUND: The seasonal influenza epidemic is an important public health issue worldwide. Early predictive identification of patients with potentially worse outcome is important in the emergency department (ED). Similarly as with bacterial infection, influenza can cause sepsis. This study was conducted to investigate the effectiveness of the Systemic Inflammatory Response Syndrome (SIRS) criteria and the quick Sequential Organ Failure Assessment (qSOFA) score as prognostic predictors for ED patients with influenza. METHODS: This single-center, retrospective cohort study investigated data that was retrieved from a hospital-based research database. Adult ED patients (age ≥ 18 at admission) with laboratory-proven influenza from 2010 to 2016 were included for data analysis. The initial SIRS and qSOFA scores were both collected. The primary outcome was the utility of each score in the prediction of in-hospital mortality. RESULTS: For the study period, 3561 patients met the study inclusion criteria. The overall in-hospital mortality was 2.7% (95 patients). When the qSOFA scores were 0, 1, 2, and 3, the percentages of in-hospital mortality were 0.6, 7.2, 15.9, and 25%, respectively. Accordingly, the odds ratios (ORs) were 7.72, 11.92, and 22.46, respectively. The sensitivity and specificity was 24 and 96.2%, respectively, when the qSOFA score was ≥2. However, the SIRS criteria showed no significant associations with the primary outcome. The area under the receiver operating characteristic curve (AUC) was 0.864, which is significantly higher than that with SIRS, where the AUC was 0.786 (P < 0.01). CONCLUSIONS: The qSOFA score potentially is a useful prognostic predictor for influenza and could be applied in the ED as a risk stratification tool. However, qSOFA may not be a good screening tool for triage because of its poor sensitivity. The SIRS criteria showed poor predictive performance in influenza for mortality as an outcome. Further research is needed to determine the role of these predictive tools in influenza and in other viral infections.

Prehemodialysis arteriovenous access creation is associated with better cardiovascular outcomes in patients receiving hemodialysis: a population-based cohort study.

BACKGROUND: Cardiovascular (CV) disease contributes to nearly half of the mortalities in patients with end-stage renal disease. Patients who received prehemodialysis arteriovenous access (pre-HD AVA) creation had divergent CV outcomes. METHODS: We conducted a population-based cohort study by recruiting incident patients receiving HD from 2001 to 2012 from the Taiwan National Health Insurance Research Database. Patients' characteristics, comorbidities, and medicines were analyzed. The primary outcome of interest was major adverse cardiovascular events (MACEs), defined as hospitalization due to acute myocardial infarction, stroke, or congestive heart failure (CHF) occurring within the first year of HD. Secondary outcomes included MACE-related mortality and all-cause mortality in the same follow-up period. RESULTS: The patients in the pre-HD AVA group were younger, had a lower burden of underlying diseases, were more likely to use erythropoiesis-stimulating agents but less likely to use renin-angiotensin-aldosterone system blockers. The patients with pre-HD AVA creation had a marginally lower rate of MACEs but a significant 35% lower rate of CHF hospitalization than those without creation (adjusted hazard ratio (HR) 0.65, 95% confidence interval (CI) [0.48-0.88]). In addition, the pre-HD AVA group exhibited an insignificantly lower rate of MACE-related mortality but a significantly 52% lower rate of all-cause mortality than the non-pre-HD AVA group (adjusted HR 0.48, 95% CI [0.39-0.59]). Sensitivity analyses obtained consistent results. CONCLUSIONS: Pre-HD AVA creation is associated with a lower rate of CHF hospitalization and overall death in the first year of dialysis.

ß-blockers after acute myocardial infarction in patients with chronic obstructive pulmonary disease: A nationwide population-based observational study.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) less often receive ß-blockers after acute myocardial infarction (AMI). This may influence their outcomes after AMI. This study evaluated the efficacy of ß-blockers after AMI in patients with COPD, compared with non-dihydropyridine calcium channel blockers (NDCCBs) and absence of these two kinds of treatment. METHODS AND RESULTS: We conducted a nationwide population-based cohort study using data retrieved from Taiwan National Health Insurance Research Database. We collected 28,097 patients with COPD who were hospitalized for AMI between January 2004 and December 2013. After hospital discharge, 24,056 patients returned to outpatient clinics within 14 days (the exposure window). Those who received both ß-blockers and NDCCBs (n = 302) were excluded, leaving 23,754 patients for analysis. Patients were classified into the ß-blocker group (n = 10,638, 44.8%), the NDCCB group, (n = 1,747, 7.4%) and the control group (n = 11,369, 47.9%) based on their outpatient prescription within the exposure window. The ß-blockers group of patients had lower overall mortality risks (adjusted hazard ratio [95% confidence interval]: 0.91 [0.83-0.99] versus the NDCCB group; 0.88 [0.84-0.93] versus the control group), but the risk of major adverse cardiac events within 1 year was not statistically different. ß-blockers decreased risks of re-hospitalization for COPD and other respiratory diseases by 12-32%. CONCLUSIONS: The use of ß-blockers after AMI was associated with a reduced mortality risk in patients with COPD. ß-blockers did not increase the risk of COPD exacerbations.

Temporal Trends in Treatment and Outcomes of Acute Myocardial Infarction in Patients With Chronic Obstructive Pulmonary Disease: A Nationwide Population-Based Observational Study.

BACKGROUND: Acute myocardial infarction is a major cause of hospitalization and death in patients with chronic obstructive pulmonary disease (COPD); however, temporal trends in the management and clinical outcomes of these patients remain unclear. METHODS AND RESULTS: We conducted an observational study by using a representative sample of 1 million beneficiaries from the Taiwan National Health Insurance Research Database. Comorbidities, in-hospital treatment, and outcomes were compared for patients with acute myocardial infarction with and without COPD between 2004 and 2013. Temporal trends in treatment and outcomes were analyzed. We included 6770 patients admitted to hospitals with acute myocardial infarction diagnoses, of whom 1921 (28.3%) had COPD. Fewer patients with COPD received ß-blockers (adjusted odds ratio 0.66, 95% CI 0.59-0.74), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (adjusted odds ratio 0.83, 95% CI 0.73-0.93), statins, anticoagulants, dual antiplatelets, and coronary interventions. These patients had higher mortality (in hospital: adjusted hazard ratio 1.25 [95% CI 1.11-1.41]; 1 year: adjusted hazard ratio 1.20 [95% CI 1.09-1.32]) and respiratory failure risk during admission. Temporal trends showed little improvement in mortality in patients with COPD over 10 years. Multivariable logistic regression indicated that dual antiplatelets, ß-blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, statins, coronary angiography, and coronary artery bypass grafting surgery were significantly correlated with improved mortality in patients with COPD. CONCLUSIONS: In Taiwan, a lower proportion of patients with COPD received evidence-based therapies for acute myocardial infarction than did patients without COPD, and their clinical outcomes were inferior. Limited improvement in mortality was observed over the preceding 10 years and is attributable to the underuse of evidence-based treatments.

To Load or Not to Load? Aspirin Loading in Acute Ischemic Stroke: A Study of Clinical Outcomes.

BACKGROUND AND PURPOSE: Aspirin is known to reduce mortality and recurrent vascular events. However, there are no reports about the dose-response of loading aspirin in treating acute ischemic stroke. The objective of this study was to compare the effectiveness of different loading doses of aspirin in acute ischemic stroke presenting within 48 hours of symptom onset. METHODS: This was a retrospective, hospital-based cohort study. Patients were classified as high dose (160-325 mg) or low dose (<160 mg) based on the initial loading dose of aspirin at the emergency department. The primary outcome measure was a favorable modified Rankin Scale (mRS) score of 1 or lower on discharge. Secondary outcomes included in-hospital mortality, stroke progression during admission, and bleeding events. A propensity score with 1:3 matching was used to balance baseline characteristics, and stepwise multiple logistic regression was performed for variable adjustment. RESULTS: From a total of 7738 available patients, 3802 patients were included. Among them, 750 patients were in the high-dose group. Multiple logistic regression after matching revealed that the high-dose group was significantly associated with a favorable clinical outcome on discharge (odds ratio: 1.49, 95% confidence interval: 1.17-1.89, P <.01), but not mortality or stroke progression. The high-dose group also experienced more minor bleeding events. CONCLUSIONS: A higher loading dose of aspirin (160-325 mg) can be beneficial in treating acute ischemic stroke, although there is an increased risk of minor bleeding.