This small study has shown that MAPSE when com- bined with APACHE II score is a good predictor of mortality. Among the echocardiographic parameters MAPSE alone was a good predictor of mortality. Cardiac biomarker Troponin I was not the significant parameter in our study. Assessment of cardiac func- tion in sepsis patient is important and serial evalu- ation and measuring of the MAPSE may help to monitor the progress of the patient. Future studies involving more number of patients and multiple ob- servers is indicated to validate results of this study.
The use of scoring systems and the audit of intensive care has not been widely reported in India. There have been few studies addressing the needs of pediatric critical care. Most scoring systems are designed in the west and need to be validated in our own country. The performance of the PRISM III score in our study showed a good performance of prediction of mortality with the ROC curve analysis having an area under the curve of just 0.853. (85% correct prediction). Singhal et al 25 found the ROC analysis to be 72% in their study using the PRISM score. Their conclusion was that the PRISM score was a good predictor of mortality. Surekha Joshi et all 27 in their study in B.Y.L. Nair Hospital, Mumbai, which was presented in All India Pediatric Conference-2006 (Pedicon’2006) , found that PRISMIII score was useful in predicting mortality. Clearly the PRISM score has performed well in our study and it is comparable to the original developers who found ROC analysis (Pollock et all 6,7 )of more than 90%.
Hypercapnia is almost always an indicator of exhaustion of ventilatory force. This is why we explored whether hypercapnia might also be able to predict mortality, which we con ﬁ rmed. In particular, acute hypercapnia (de ﬁ ned as pH <7.35) is a relevant predictor of mortality. Almost every third patient (32%) died 1 year after acute hypercapnia was detected at hospital admission. Patients with chronic hypercapnia had a slightly lower 1-year mortality rate (20%). Additionally, there were differences in the 1-year mortality rate depending on the underlying cause of the hypercapnia. Patients with obesity hypo- ventilation syndrome or hypercapnic obstructive sleep apnea syndrome almost never died when treated properly with noninvasive ventilation. In contrast, patients with pneumonia had a very high mortality rate (50%) and the mortality rates for chronic obstructive pulmonary disease and congestive heart disease were also considerable, at 24% and 28%, respectively.
Assessment of diastolic function by echocardiography has shown a high incidence of abnormalities in dialysis and non-dialysis CKD patients [23,24]. Some investigators have found abnormalities in tissue Doppler velocity in virtually all patients with CKD, suggesting a degree of subclinical myocardial disease in all such patients . In the CRIC study (stage 2–4 CKD) diastolic function was abnormal in 71% of patients . In our cohort some degree of dia- stolic dysfunction was present in 85% of patients and 35% had grade 2 or higher diastolic dysfunction, which was a powerful independent predictor of mortality. Patients with abnormal diastolic function have been found to have in- creased integrated backscatter which is a measure of colla- gen content of myocardial tissue . We used E/é as part of our grading of diastolic function and this has been shown to reflect LV filling pressure and has been associ- ated with mortality in CKD patients .
Sreeharsha S et al have done a prospective observational study concluded that SNAPPE II score is a good predictor of mortality but does not accurately predict the length of the stay with PPV of 95.3%, sensitivity of 76.9% and specificity of 87.1%. Compared to present study (specificity 47%), this study had high specificity (87.1%) and a good PPV which highly signifies the association between the score and the mortality rate. 4
Our data from a large prospectively collected cohort of unse- lected ambulatory patients with CHF suggest that 25[OH] D deficiency (25[OH]D < 50 nmol/L) is highly prevalent, persists during summer and autumn, and is an independent predictor of increased mortality. After adjusting for multi- ple confounders, the outcome data from the cohort study are consistent with previous smaller reports in ambulatory patients [9, 21, 22], hospitalised patients  and registry data [3, 6, 23], and reveal increased mortality in patients with low 25[OH]D concentrations compared with those without. In all of these previous studies, 25[OH]D deficiency was less frequent than in our cohort ranging from 28 to 75% [10, 24], whilst overall mortality of the cohorts was higher. Our cohort study was prospectively designed to assess pre- dictors of outcome in an unselected, consecutive group of patients with heart failure due to left ventricular systolic dysfunction on optimal contemporary medical and device therapy, and provides the strongest evidence to date that a low 25[OH]D concentration is an independent predictor of mortality.
Coma Scale (GCS) as a superior predictor for inhospital mortality in comparison to Pediatric Trauma Score (PTS) [13, 14] and Injury Severity Score (ISS) raising concerns about the suitability of using anatomical based scoring systems. Potoka et al. developed novel scoring system based upon age-specific physiological criteria and concluded physiological-based score as a tool for predic- tion of survival . Previous attempts to compare and validate different scoring systems in pediatric patients have yielded varying results [15 – 17]. However, an ideal tool for prediction in pediatric trauma remains elusive. The performance of trauma score may vary on the dif- ferent systems of care as well as different mechanism of injury.
With respect to glucose levels, there are also reports of different mortality patterns observed in patients with and without diabetes. Patients with diabetes tolerate higher glycaemic values, without repercussions on mor- tality, conceivably possessing some, as yet unknown, protective factors against stress hyperglycaemia. These facts, together with the finding that in the first week post-OLT diabetic patients display glucose profiles dif- ferent to those of non-diabetic patients, led us to analyse these two groups of patients separately. As can be seen from Fig. 1, patients with diabetes started with higher plasma glucose values on the first day, which then gradu- ally declined after the first 48 h. In contrast, non-diabetic patients started from appreciably lower figures which gradually rose until reaching a peak at 48–72 h, and then
done by Min Ho Seo in 2016 with hypoalbuminemia, low base excess value and tachypnoea to predict 28 day mortality in severe sepsis and septic shock patient in emergency department, which found that mortality in patients with sepsis and septic shock correlates with increased base excess level. It is found that base excess has slight higher area of under the ROC curve (AUROC=0.864) in comparison with APACHE II (AUROC = 0.782) which corelates with the above study done by Min Ho Seo. Study done by Min Ho Seo showed the AUC of the APACHE II score to be 0.6177(95% CI,0.5423-0.6931) 12whereas albumin, base deficit and respiratoryrate combined had AUC of 0.8173(95% CI,0.7605-0.8741) and conclude that, base excess can be chosen for predicting mortality then APACHE II. Our study had mean APACHE of 16 (S.D = 5.92) in survival group and 23.3 (S.D = 6.94) in mortality group , while study done by Sundaramoorty et al had mean APACHE of 24.3 in survival group with S.D of 6.48 and 32.39 in mortality group with S.D of 5.09. 21
For any particular test (a laboratory value or scoring system), various cutoff points are plotted as sensitivity (true positives) against true negatives (1- specificity). The resulting curve is the ROC curve. The curve demonstrates the discriminative power (to separate for example recovery from death in a mortality score) at various score points. The test is said to have good performance if the area under the curve nears 1. A 0.5 result is interpreted as worthless as this could be by pure chance and the laboratory test or scoring system has not had a good discriminative power. The following ROC curve (Fig. 1) demonstrates the area under the curve and its interpretation.
istic (ROC) curves were constructed for risk predictors by plotting 1 – specificity versus sensitivity. ROC curves were quantified by the area under the curve (AUC). To test the difference between ROC curves, bootstrapping was employed based on the creation of pseudo-replicate datasets by random resampling of the dataset n times for error estimation (n=1000 in this study). The associ- ation of risk variables with the endpoints was tested by univariable and multivariable logistic and Cox-regression analyses. Multivariable analyses included NRR as well as the GRACE score and the LVEF. In the analysis for the 2-year mortality, female gender and diabetes were also taken into account. To test the incremental prognostic value of NRR on top of the GRACE risk model, we imple- mented C-statistic, continuous NRI and the integrated discrimination improvement (IDI) score. Mortality rates were estimated by the Kaplan-Meier method. HRs were presented with 95% CIs. When used as categorical vari- able, the NRR was dichotomized at the cut-off value of 16.8 breaths/min. The cut-off value was determined by a method described by Youden et al. 13 Differences were
regression. The outcome of interest was defined as mor- tality, with transplantation as competitor. Results for this initial model are shown in Table 4 (top frame). Scl levels were positively associated with increased mortality over the follow-up period (HR 2.18; 95% CI 1.41-3.38). When Scl levels were categorized as high and low while keep- ing all other variables, high Scl levels were associated with a HR of 2.88 (95% CI 1.35-6.15). Cumulative inci- dence function for high Scl levels for mortality is shown in Figure 1. After the additive model exploration, the final model (with lowest BIC values) included only, age (HR 1.04; 95% CI 1.02-1.07), Scl levels (HR 2.20; 95% CI 1.35-3.56) and presence of diabetes (HR 2.27; 95% CI 1.14-4.54), as shown in Table 1 (bottom frame). Due to limited sample size, dialysis vintage was modeled in a distinct model, confirming that high Scl was still associ- ated with mortality with an Exp (coef ) of 2.98; 95% CI 1.35-6.33. The other variables retained were also age and diabetes.
Results A total of 260 Code Blue activations were made, out of which there were 203 true cardiac arrest events among 40,168 in-patients; the cumulative incidence of the same was 0.51%. Mean (SD) duration of arrival of the Code Blue Team (CBT) to the scene was 64.5 (27.7) seconds. Cardiovascular illness was the predominant baseline morbidity but none of the baseline illness showed increased risk of mortality in this group. Among true cardiac arrest events, 92.6% was due to pulseless electrical activity/asystole and 7.7% was due to ventricular fi brillation (VF)/pulseless ventricular tachycardia (VT); both of these did not have any diff erence on the initial outcome. But having an initial rhythm of VF/pulseless VT had 90% more chance for discharge from the hospital, with P = 0.04. Although arrival time of the CBT did not have any infl uence on the fi nal outcome, duration of resuscitation ≤20 minutes had an odds ratio of 10.6 with P <0.001 favoring return of spontaneous circulation over death after controlling for age. Of the 203 patients who had true cardiac arrest events, 43 (21.2%) were discharged from the hospital. Good neurological outcome at discharge was seen among 22 (10.8%) of the patients based on Cerebral Performance Category Score. Conclusion Our experience shows that out of every 1,000 patients admitted to our hospital, about fi ve sustained cardiac arrest, of whom only 11.3% survived to hospital discharge with good neurological recovery. Variation in the eff ectiveness of the cardiopulmonary resuscitation quality in comparison with world data could be due to the inherent diff erence in the severity of the primary illness in the patients and diversity in the reported data.
especially in older ages (1,2). On the other hand, negative fluid balance is an independent risk factor for lower mortality and reduction in ICU stay and ventilator requirement especially in critically ill patients with acute kidney injury (3). Negative fluid balance was also associated with reduction mortality in acute care surgery patients (4). In addition of fluid balance, oliguria is associated with higher mortality in critically ill patients, especially in patients with acute kidney injury (5). On other hand, osmotic urea dieresis with consequent hypernatraemia is a predictor of mortality in critically ill patients (6). Although many etiologies can be identified in patients with polyuria, with two principal causes including aqueous polyuria and osmotic polyuria (7), we hypothesized patients with polyuria have probably more ability in fluid excretion and consequently more cardiovascular fitness.
The ability to predict future morbidity and mortality is a key to reduce the burden of CKD. To this end, monitoring a patient's functional and subjective status of well-being, collectively known as health-related quality of life (HRQOL), is of particular importance in CKD patients [4- 7]. Traditional risk factors (e.g., atherosclerosis, smoking, and diabetes mellitus) for mortality had been considered important in the elderly with or without CKD [8,9]; how- ever, it is currently thought that traditional risk factors do not account for all reported mortality . Recently, HRQOL, comprising physical, mental, and social health, is recognized as an important predictor of mortality in elderly individuals or patients with end-stage renal disease [5,7,11,12]. However, nephrologists have shown little interest in the role that HRQOL plays in mortality in CKD patients .
Knowledge of mortality risk factors in TB patients may improve their survival. With regard to the importance of lowered CD4 cell counts in predicting a poor prognosis for TB patients and due to the lack of flow-cytometric devices in low– income, high- contamination countries, it seems logical to look for an available and simple alternative as a predictor. In this study, we demonstrate that lymphocytopenia detected in peripheral blood count may be a useful predictor of mortality in TB patients.
OF HYPONATREMIA AS AN INDEPENDENT PREDICTOR OF SHORT TERM MORTALITY AND ADVERSE CARDIAC EVENTS AMONG HOSPITALIZED PATIENTS OF ACUTE STEMI", submitted by Dr. ARUN KAUSHIK . P., Post-Graduate in General Medicine, Coimbatore Medical College, to The Tamilnadu Dr. M.G.R. Medical University is a record of a bonafide research work carried out by him under my guidance and supervision from January 2007 to June 2009.
We have illustrated that time from collapse to ROSC < 20 minutes is a positive predictor for survival and neuro- logical outcome. Similar results have been shown in other studies [12,14,19]. When combining initial rhythm and time to ROSC, a remarkable finding is that the initial rhythm is the most important predictor for both survival and neurological outcome. In other words, the duration of non-sufficient circulation is not as important for survival and neurological outcome as the initial cardiac arrest rhythm. When having non-VT/VF, the time to ROSC is insignificant for both survival and neurological outcome in this study. Our results are verified by Herlitz et al. , who demonstrated that initial rhythm is the strongest pre- dictor for survival, followed by time from call for and arrival of the ambulance, used as a marker for time to ROSC. However, there is a possibility that the initial rhythm itself can have an influence on time to ROSC, since a shockable rhythm can often be defibrillated into a perfusing rhythm. Our data describing mortality, initial rhythm and time to ROSC, show a trend towards a lower mortality among patients with cardiac etiology, but as the number of patients in each subgroup is small, it is difficult to draw any conclusions.
rather than instead of clinical assessment. This is in line with previous studies investigating patients with sepsis or septic shock that found PCT and CRP to have limited abilities to predict outcome [36–38]. However, we found that the AUC improved when the inflammatory markers were combined. It may indicate that PTX3 in combin- ation with other inflammatory markers can be used to discern severe NSTI from milder courses in order to re- fine the risk stratification. In particular, PTX3 level was higher in patients needing amputation during the first 7 days in the ICU, whereas PCT and CRP were not. Therefore, PTX3 might be used to identify the high-risk patients who require aggressive surgery, while directing a conservative approach to low-risk patients. The correl- ation between PTX3 and SAPS II may also suggest that PTX3 can be used as an easy assessment of disease se- verity until SAPS II can be calculated or in cases where SAPS II cannot be calculated due to missing values. An explanation for the association between high PTX3 level and increased disease severity and mortality may be found in the biological action of PTX3 as it is released in response to proinflammatory stimuli from interleukin-1 and tumor necrosis factor, thus potentially reflecting higher bacterial loads. PTX3 also acts as a modulator of the complement system, but a pathophysiological role re- lated to tissue damage by amplifying the complement pathways remains to be elucidated.
Patients suffering from schizophrenia have a mortality risk that is two to three times that of the general popu- lation and the leading cause of death is cardiovascular disease (CVD) [1,2]. Although, multifactor causes have been identified, reduced cardiorespiratory fitness has probably been overlooked as a risk factor for CVD in patients with schizophrenia .