High doses of beta-blockers and alcohol abstinence improve long-term rebleeding and mortality in cirrhotic patients after an acute variceal bleeding.

BACKGROUND & AIM: We analysed prognostic indicators of long-term outcome in cirrhotic patients surviving the critical 6-week period after an episode of acute variceal bleeding. METHODS: All patients with oesophageal variceal bleeding from 2001-2007 were prospectively registered. Follow-up extended from day 42 after index bleeding to last visit, death or liver transplantation (LT). Multivariate Cox regression analysis was performed. RESULTS: Two hundred and fifty variceal bleeding episodes were registered. Fifty-four patients (26%) died before day 42, and 123 patients were finally included. Median follow-up was 23.5 months. Nadolol+/-nitrates alone or combined with variceal ligation were used as prophylaxis in 93% of patients. During follow-up, 43 patients (35%) experienced rebleeding, 34 (27.5%) died and 10 (8%) were transplanted. Follow-up beta-blocker dose (HR 0.993, 95% CI 0.987-0.998, P=0.027) and alcohol abstinence (HR 0.324, 95% CI 0.152-0.691, P=0.004) were independent rebleeding predictors. The Cox analysis disclosed the Child-Pugh score (HR 1.24, 95% CI 1.08-1.43, P=0.002), creatinine (HR 1.82, 95% CI 1.17-2.82, P=0.008), beta-blocker dose (HR 0.992, 95% CI 0.987-0.997, P=0.003), viral cirrhosis (HR 2.72, 95% CI 1.31-5.67, P=0.008), hepatocellular carcinoma (HR 9.44, 95% CI 3.54-25.20, P<0.001) and alcohol abstinence (HR 0.29, 95% CI 0.13-0.62, P=0.002) to be independent prognostic markers for mortality/LT. CONCLUSION: High doses of beta-blockers and alcohol abstinence decrease rebleeding and mortality in cirrhotic patients surviving the 6-week period after acute variceal bleeding.

Predicting 6-week mortality after acute variceal bleeding: role of Classification and Regression Tree analysis.

BACKGROUND: Available prognostic scores for mortality after acute variceal bleeding are mainly based on logistic regression analysis but may have some limitations that can restrict their clinical value. AIMS: To assess the efficacy of a novel prognostic approach based on Classification and Regression Tree -CART- analysis to common easy-to-use models (MELD and Child-Pugh) for predicting 6-week mortality in patients with variceal bleeding. METHODS: Sixty consecutive cirrhotic patients with acute variceal bleeding. CART analysis, MELD and Child-Pugh scores were performed to assess 6-week mortality. Receiver operating characteristic (ROC) curves were constructed to evaluate the predictive performance of the models. RESULTS: Six-week rebleeding and mortality were 30% and 22%, respectively. Child-Pugh and MELD scores were clinically relevant for predicting 6 weeks mortality. CART analysis provided a simple algorithm based on just three bedside-available variables (albumin, bilirubin and in-hospital rebleeding), allowing accurate discrimination of two distinct prognostic subgroups with 3% and 80% mortality rates. All MELD, Child-Pugh and CART models showed excellent and comparable predictive accuracy, with areas under the ROC curves (AUROC) of 0.88, 0.84 and 0.91, respectively. CONCLUSIONS: A simple CART algorithm combining albumin, bilirubin and in-hospital rebleeding allows an accurate predictive assessment of 6-week mortality after acute variceal bleeding.

Predicting early mortality after acute variceal hemorrhage based on classification and regression tree analysis.

BACKGROUND & AIMS: Available prognostic models for mortality after an acute variceal hemorrhage have limitations that restrict their clinical value. We assessed the performance of a novel prognostic approach based on classification and regression tree (CART) analysis. METHODS: Logistic regression (LR) and CART analyses were performed to identify prognostic models for mortality at 6 weeks in a single-center cohort of 267 consecutive patients with acute variceal bleeding. Receiver operating characteristic (ROC) curves were constructed to assess the performance of the models. Prognostic models were fitted and validated by split-sample technique (training set, 164 patients, 2001-2005; test set, 103 patients, 2006-2008). RESULTS: After 6 weeks, 21% of patients experienced rebleeding and 24% died. The best LR model was based on Child-Pugh score, creatinine level, bacterial infection, and hepatocellular carcinoma. CART analysis provided a simple algorithm based on the combined use of just 3 variables (Child-Pugh score, creatinine level, and bacterial infection), allowing accurate early discrimination of 3 distinct prognostic subgroups with 8% (low risk), 17% (intermediate), and 50% to 73% (high) mortality. Its accuracy was similar to the LR model (area under the ROC curves, 0.81 vs 0.84; P = .17) and better than that of Child-Pugh (0.75; P = .05) and model for end-stage liver disease (0.74; P = .05). The prognostic accuracy of both LR and CART models was validated in the test set (area under the ROC curve values, 0.81 and 0.83, respectively). CONCLUSIONS: A simple CART algorithm based on Child-Pugh score, creatinine level, and infection allowed an accurate predictive assessment of 6-week mortality after acute variceal bleeding.

Platelet thromboembolism after lung transplantation.

Lung transplant patients have an increased risk of pulmonary embolism which is often associated with hypercoagulability disorders. We present a case of sudden death resulting from pulmonary intravascular platelet thromboembolism following a single-lung transplant.

Respiratory pasteurellosis: infection or colonization?

Respiratory infection by Pasteurella multocida is uncommon and usually occurs in patients with an underlying lung disease, advanced age and/or immunodepression. In this study, we describe the clinical and microbiological characteristics of a series of 14 patients in whom Pasteurella multocida was isolated from lower respiratory tract samples, over a period of 21 y (1986-2006). Differentiation between colonization and infection allows establishment of early antibiotic treatment.